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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 James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2023-11-22","11/22/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/29/2018.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1790767119","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","1790767119","","2025-06-03","Location updates complete. Provider showing active at 4214 Andrews Hwy Ste 103 and 240. Jen Videan"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19","5117734","","2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01","679507","0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-07-19","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19","1046218","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22","1790767119","","2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-23","11483093","","2025-12-18","CAQH profile reattested by another user on 11/12/25, all information up to date. Next attestation due on 03/12/2026. ML"]
["Douglas James Colson, MD","1790767119","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","002539407","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","","","","2025-07-25","7/25/2025 Per email from Jennifer Videan providers CAQH profile is now Client Maintains-dvineyard"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-03-25","Received welcome letter. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-03-25","Received welcome letter. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-05-05","Address was loaded to current enrollment record. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-05-05","Address was loaded to current enrollment record. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","382485601","079837301","2025-06-09","Last name has been updated to Brown and address, 3620 N Big Spring St Midland TX has been added effective 05/05/2024. Jen Videan"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30","1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2025-05-08","14145595","","2025-03-19","3/19/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1023520830","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-19","12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-09-01","1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01","3094146","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2017 PID # 3094146\ntisha rader"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1104237015","","2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01","1790767119","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19","","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2025-09-02","14218808","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-08-27","08/27/2020 - Rec'd email back from the payer stating \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Coby Robins-Effective 08/13/2018\"  - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18","1104237015","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-10-05","Enrollment thru PHCS"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1104237015","752133441","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kim Frazier"]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-09-17","1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09","","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-01-24","Received email confirmation provider is par, linked to TIN & location, eff. 9/13/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Wellmed","Participating","Enrollment Complete","2024-02-06","","","2025-01-24","Received product roster. Provider is par, linked to TIN/location, eff. 02/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-01-08","Received email from payor confirming provider is PAR, linked to TIN/location, eff. 11/1/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2024-02-06","","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Multiplan","Participating","Enrollment Complete","2024-02-06","","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06","","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","8007338","","2025-08-11","08/05/2025 MP: Called 1-800-353-1232 and spoke w Rald at Aetna. Stated provider is PAR with GRP and TIN effective 11/06/2023. PIN is 8007338. Loc not on file. To add, submit LOI with W9 via FAX 859-455-8650 Attn to. Network Management. Call ref 256059921."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-23","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Cigna","Participating","Enrollment Complete","2024-02-01","0446524","","2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2023-11-01","","","2025-09-08","Reference #20780008 - Adding address of suite 240 has been submitted 9/8/2025 (rp)"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Medicaid","Participating","Enrollment Complete","2024-09-03","","","2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06","","","2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2024-02-06","","","2025-02-13","As per Mindy Wiggins via Teams meeting 2/13/2025,  provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1386135713","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted","2024-04-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","First Health Coventry","Participating","Add Info Submitted","2024-04-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Add Info Submitted","2023-10-09","","","2025-04-15","Submitted request via delegated roster to have 2012 Ohio location removed and ensure provider is linked to 400 Rosalind Redfern location. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Humana","Participating","Add Info Submitted","2023-10-09","","","2025-04-15","Submitted request via delegated roster to have 2012 Ohio location removed and ensure provider is linked to 400 Rosalind Redfern location. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06","8007338","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Enrollment Complete","2024-02-06","8007338","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06","8007338","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Payor Follow Up","2024-02-06","8007338","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01","0446524","","2023-12-04","Received approval email effective 12/01/23. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Per tricareproviderinquiries@triwest.com, no active contract. Jen Videan"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-11-03","11/3/2023 CAQH profile maintained by practice.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-01","8096880","","2024-01-03","Received confirmation. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. PA."]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to the group eff 11/6/23. MS"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","008167479","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Rcvd email confirmation from Jessica Bess at Multiplan that November roster has been processed and provider is PAR w/ group effective 11/6/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-10-13","","","2024-05-02","Received email from Marcus Wester (mwester@humana.com) provider has been linked to location, eff. 10/13/2023. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-02-01","6819516","","2024-01-09","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-12-03","","","2024-12-03","Location is added to group record and provider is linked to group. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-08-26","08/26/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2020-07-20","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 1/1/2020. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1841780806","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-06-21","Received confirmation from Marcus Wester provider is PAR and linked to TIN/location, eff. 08/01/2023. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-06-27","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 9/13/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-14","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 06/14/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2022. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","6910036","","2023-09-19","09.19.2023 S/W Joe of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 06/19/2023. PIN: 6910036. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163696629. - Willie Ravas"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-17","Received email confirmation provider is enrolled, linked to TIN/location, eff. 07/24/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN and location, eff. 7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-28","1841780806","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff.  7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-01-22","","","2025-01-22","Received confirmation via BCBSTX email Provider participating. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-12-02","6819516","","2025-02-24","Received confirmation from Cigna. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Provider is confirmed. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2020-07-20","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff.  7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1841780806","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-28","1841780806","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-07-03","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff 07/03/2022. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-28","1841780806","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2022-06-01","","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2022-06-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","First Health Coventry","Participating","Application Resubmitted","2022-06-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-28","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","00008092273024","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-18","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-14","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 06/14/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-02-20","7M9102","","2025-06-25","Per PECOS provider is active and linked to group. Location is active. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 9/13/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2022-06-01","3567571","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","First Health Coventry","Participating","Application Resubmitted","2022-06-01","3567571","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2017-09-01","1841780806","","2025-08-18","08/15/2025 AC: Checked Texas Mutual's directory to check provider status, provider is participating. Verification request has been emailed to wwtxcontracts@texasmutual.com to verify provider effective date."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN effective 07/01/2024. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-06-19","6819516","","2023-09-19","09.19.2023 S/W Sofie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 6819516. Service location is on file. Call ref#:SofieS09192023."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","","CAQH profile reattested, all information up to date. Next attestation due on 3/19/26. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","1841780806","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","1225283963","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 1/26/2017 for all locations. PIN is the NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2023-05-25","","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Zurich","Participating","Enrollment Complete","2023-05-25","","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Payor Follow Up","2023-04-14","","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","1225283963","","2025-05-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1225283963","","2025-05-28","Per providerdata@careworks.com, name change request has been processed. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2025-04-14","Received email from Karen Avalos confirming February roster was processed. Provider par, eff. 04/14/2023. PA."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-04-28","Per updates@primehealthservices.com, Her last name is Lucas. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-04-28","Per updates@primehealthservices.com, Her last name is Lucas. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 1/11/2024 all locations but providers last name is different. PIN is NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 1/11/2024 all locations but providers last name is different. PIN is NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider participating as of 5/25/2023 via roster. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-12-28","12/28/2023 Per UHC web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","1225283963","","2025-04-28","Per michelle.killough@pswca.org, I have downloaded her license reflecting the change. I will make it in our system. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2025-05-01","The application to update the providers last name has been approved. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2023-07-01","","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 07/01/2023. PA"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-09-23","","","2025-12-08","CAQH reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","1225283963","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 8/1/2023 for all locations. PIN is the NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2023-05-01","003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-04-05","","","2025-03-04","Received confirmation via email from First Health, provider par as of 4/5/2024 under last name Wood. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2025-05-30","Name change has been approved and closed (Wood to Lucas). Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-04-14","","","2023-10-13","10/13/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Payor Follow Up","","","","2025-12-02","Emailed mhtcontractrequest@molinahealthcare.com along with W9 for enrollment process, Molina stated they did not have the original request. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2018-07-31","1740542034","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","1991-09-01","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1740542034","","2020-06-10","06/10/2020 - Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","1740542034","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2018-09-01","1740542034","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","1740542034","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1740542034","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","1740542034","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-12-06","","","2024-09-09","Confirmed provider is linked to this location. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3165726","","2020-03-20","03/20/2020 - Recd email from the payer stating this provider is effective under PID# 3165726  - Stacey Hudak"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1740542034","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2018-08-01","1740542034","","2025-08-08","08.04.2025 JB: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2018-08-01","","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2025-05-05","","","2025-09-08","Received notification via online chat box (spoke with Derek, ref. # 05415338) confirming provider's participation with network effective 05/05/2025. ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2018-08-01","","","2025-08-18","08/18/2025 AC: Called 1-800-353-1232 and spoke w Madie R at Aetna. Stated provider is PAR but not link to TIN need to submit link letter through fax#: 8594558650, attn to: network management and attach w9 form. TAT: 30 bus days PIN: 6125319. Call ref number 259521106"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","PPHP","Participating","Enrollment Complete","2025-05-05","","","2025-05-27","Received email from Keandra W. confirming  May roster has been processed. Provider now linked to TIN/location, eff 5/5/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2025-05-05","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 5/5/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2025-05-05","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS, provider participating as of 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2025-04-01","Q01054587","","2025-06-18","Provider approved. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1265798763","","2025-10-07","Per tricareproviderinquiries@triwest.com, provider is loaded under contract. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2025-05-05","","","2025-07-10","Received confirmation via email from Emily Starr, provider participating eff 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2025-05-05","","","2025-07-16","Received email from Marcus Wester confirming provider is par, linked to TIN/location, eff. 5/5/25. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2025-04-01","","","2025-06-26","Approval ltr rcvd. Effective 04/01/2025. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","BCBSTX","Participating","Enrollment Complete","2025-05-23","","","2025-05-28","Received welcome letter from BCBSTX confirming the provider is participating, linked to group,  effective 05/23/2025. The provider is enrolled in the following networks: BCA - BlueChoice PPO, HME - Health Select, HMO - Blue Essentials, WEL - WellMed MA HMO, BAV - Blue Advantage HMO, MCH - Medicare Advantage HMO, PMC - Medicare Advantage PPO, and SNP - Dual Eligible Special Needs Plan. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2025-09-02","3970095","","2025-09-03","Per discovercigna@information.cigna.com,  Dear SULAY PATEL, Congratulations! It is my pleasure to welcome you to the Cigna HealthcareSM medical network. Physicians like you – and the care teams that surround you – are essential to ensuring the health and vitality of your patients. \n\n•\tYour effective date is 09/02/2025.\n•\tYour provider identification number is 3970095. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2025-05-05","","","2025-06-27","Received email from Karen Avalos confirming provider is linked to TIN/location, eff. 5/5/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2025-06-01","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 06/01/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2025-05-05","","","2025-10-22","Per roster from Mindy sent on 10/21/25 this provider is effective 5/05/2025-SG"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2025-05-05","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS, provider participating as of 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2025-05-05","","","2025-09-08","Received notification via online chat box (spoke with Derek, ref. # 05415338) confirming provider's participation with network effective 05/05/2025. ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-11-17","CAQH Profile reattested. All information up to date, next attestation due on 3/17/26. ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2025-04-01","7N6523","","2025-05-22","Received welcome letter. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Triwest VA","Participating","Enrollment Complete","2025-09-15","","","2025-09-11","Received email from scarlett_abigail@bcbstx.com stating provider is now completed with effective date of 09/15/2025. MR"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2025-05-05","","","2025-06-27","Received confirmation vial email from Mary Rodriguez, provider participating eff date 5/5/2025. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-05-20","1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-08","CAQH profile reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2020-01-05","412587401","325373401","2025-11-13","Revalidation for TMHP has been approved. 2/26/2026-02/05/20231. Request # is 20819200. VA"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","1346807278","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-05-13","1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1346807278","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","1346807278","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","2021-01-26","1312287","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2020-01-05","Q00111613","DU2795","2025-02-20","Enrollment Confirmed. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-07-02","","","2024-09-09","Provider has been confirmed linked to this location. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1346807278","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25"," 1346807278","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2024-08-29","Received confirmation from Cassandra Dunagon provider is participating with all products. FC"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1649462987","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-08-01","387144401","364596201","2023-12-19","Revalidation approval letter rcvd. Effective 08/01/2018. Jen Videan"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1649462987","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","2506877","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2506877 - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1649462987","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","685085","519061","2020-04-22","04/22/2020 - found EFF info through group PECOS enrollment - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1649462987","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-08-19","8/19/2020 - Rec'd a new spreadsheet from Baylor Scott & White after they merged databases with First Care. Updated the effective date and this provider is showing up affilaited with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179384","DW7662","2020-04-22","04/22/2020 - Confirmed provider EFF info through payer portal - Stacey Hudak"]
["Gautham Subhash Gadiraju, MD","1649462987","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-02-12","1407149883","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1407149883","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1407149883","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-09-01","P02262526","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 09/01/2018 with provider number P02262526. Attached welcome letter to payor line\n--tisha rader"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-08-27","1407149883","","2020-09-23","09/23/2020 - Reviewed follow up complete note and moved to completed status - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-08","CAQH profile reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","3060094","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3060094 - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-09-01","377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Payor Follow Up","2018-11-15","1407149883","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-09-01","691156","519061","2020-02-19","02/19/2020 - Rec'd PECOS login .Signed in to find that this provider is successfully enrolled with Medicare/MIMA as of 9-1-2018. - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1407149883","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-07-30","7/30/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/27/2020.  DCannon"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-06-03","Per Aetna rep Irish G, 1-800-353-1232, reference #6194100173, provider is  PAR, effective 3/11/2024, linked to TIN and location. PA"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2024-03-11","","","2024-08-30","Received confirmation via email from Aleece Moerbe provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2024-03-11","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  03/11/2024.  PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-04-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective  4/15/2024, and is linked to the TIN and location. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-02-12","7487489","","2024-04-05","Received confirmation of enrollment via email. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2024-03-13","","","2024-08-08","Provider PAR with Star, Star kids, and Star + eff date 3/13/2024 as per roster received from Cassandra via email. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-12","Location is not Tricare Credentialed, panel is closed. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-08-08","Provider participating as of 4/1/2024 listed as Pediatrics, spoke to Tash call ref#11607782. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2024-03-12","","","2024-04-29","Provider is linked to this location eff 3/12/24. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Per tricareproviderinquiries@triwest.com, no active contract. Jen Videan"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-28","","","2024-08-16","Received confirmation from Mary Rodriguez via e,mail, provider participating as of 12/28/2023. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2024-03-11","","","2024-08-08","Received confirmation provider is PAR and linked to TIN/location, eff. 3/11/2024. Product roster uploaded. PA."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","2018-01-16","560990YSCJ","290001","2020-07-24","7/24/2020 - Confirmed this provider is linked to Quick Care Clinic Part B group PTAN 290001 - Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Boon Chapman","Participating","Enrollment Complete","2020-07-17","","","2022-09-15","9/15/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Molina","In Process","Payor Follow Up","","","","2025-08-25","08/25/2025 AC:  Called 1-855-322-4080 and spoke w Rove at Molina. Stated that prov is out of network, unable to check applications. Rep advise to email Contracting Team at mhtcontractrequest@molinahealthcare.com. Verification request has been emailed to mhtcontractrequest@molinahealthcare.com. to verify provider credentialing status."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1740723725","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed roster - Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312289","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2020-09-01","6427230","","2025-08-12","08/05/2025 TE: Called 1-800-353-1232 and spoke with Tine at Aetna. Provider is linked to the TIN as in network effective 09/01/2020. Location is on file. PIN 6427230. Call ref# 256067362"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2023-05-16","05.16.2023 S/W Jerome of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2020. Provider ID 3385653, No Payer ID and No Recredentialing date. Service location is on file. call ref#:633322.-Danico Gabriel Melendres"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-17","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-04-30","1740723725","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","1740723725","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider has been added to the PRIMED DELEGATED AGREEMNT under this TIN/Service Location. The provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1740723725","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2018-04-01","","","2020-09-24","Confirmed via self-service portal, provider is participating under group Tax ID and location. Kimberly Frazier"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1740723725","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2018-01-16","378143702","324676101","2021-02-10","2/10/2021 Per email received from Stacy Salazar, she processed provider's application, which has been approved and assigned TPI 378143702 effective 1/16/2018. KFrazier"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1740723725","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 7/17/2021.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2019-05-10","1588857874","","2024-07-24","Approval Ltr rcvd. Effective 05/10/2019. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2020-04-03","1588857874","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 04/03/2020. PA."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-12-08","CAQH Reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-22","Revalidation approval ltr rcvd. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","380896603","331090601","2020-07-15","07/15/2020 - logged into TMHP and found that this provider is EFF - TPI 380896603 - Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1588857874","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Payor Follow Up","","","","2025-12-02","Emailed mhtcontractrequest@molinahealthcare.com along with W9 for enrollment process, Molina stated they did not have the original request. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-09-01","1588857874","","2020-02-10","02/10/2020 - Rec'd confirmation from payer that this provider is EFF at 5615 Deauville, Ste 220 through a DELEGATED PAYER (Permian Basin Healthcare Network) and linked to the following products: STAR, HEALTH FOSTER CARE, STAR, STAR PLUS, CHIP RSA,\nSTAR KIDS, CHIP, CHIP PERINATE, also EXCHANGE (exchange only since 1-1-2014; non par) All other products are PAR since 9-1-2019. - Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","2650428","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2019-05-10","1588857874","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 4-4-2019 under a DIRECT CONTRACT at this service location."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-06-01","1588857874","","2025-01-16","Received email confirmation on 01/07/2025 confirming provider reinstated with an effective date of 06/01/2019 for Aetna commercial plans and IFP/ Exchange CVS HMO plan. PA."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-03-01","P02232681","DU5783","2020-02-21","02/12/2020 - Found effective info through payer site stating provider is PAR with group PTAN:  DU5783 EFF 3-1-2019. - Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2020-04-03","1588857874","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 04/03/2020. PA"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-04-27","1588857874","","2024-05-07","Provider active with Corvel. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1588857874","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","1588857874","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 5/1/2019 for all locations. PIN is the NPI."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/6/2019.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1588857874","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2020-04-03","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1588857874","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1588857874","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2025-05-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 5/1/2025. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1164778767","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1164778767","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","1164778767","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/01/2019 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-12-08","CAQH reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-11-18","1164778767","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-12-31","1164778767","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/26/2017 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","1164778767","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/01/2019 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2020-03-20","1164778767","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 03/20/2020. PA"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-11-18"," 1164778767","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2020-03-20","1164778767","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 03/20/2020. PA."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2024-02-21","Rcvd revalidation approval ltr. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","3039403","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2020-03-20","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-06-01","","","2025-01-16","Received email confirmation on 01/07/2025 confirming provider reinstated with an effective date of 06/01/2019 for Aetna commercial plans and IFP/ Exchange CVS HMO plan. PA."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1164778767","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/11/2024 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-06-01","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 6/1/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-23","13859704","","2025-12-08","CAQH profile reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1639524861","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-12-02","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 12/2/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 10/15/2019. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","2017791","","2025-08-11","08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is participating and link under the group and TIN PIN is 2017791. Physical location is on file. Call ref# Aby S 08/05/2025."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02252784","","2024-12-20","Confirmed providers enrollment. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2019-07-05","","","2025-05-27","Received product roster from UHC rep, Charlie. Suite 103 location successfully added. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 5/31/2019. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-03","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 5/3/2019. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2025-02-21","Received email from Network Relations-Humana, confirming provider is par, linked to TIN/location, eff.  01/1/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-06-01","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 06/01/2024. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-01-16","","","2025-03-25","Approval ltr rcvd. Effective 01/16/2024. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-06-01","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 6/1/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","CAQH","Active","CAQH Reattested","","","","2025-12-08","CAQH profile reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-07-05","","","2025-05-27","Received product roster from UHC rep, Charlie. Suite 103 location successfully added. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-12-02","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 12/2/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-01","","","2025-02-04","Received confirmation via email from Jessica Bess, provider participating as of 6/1/2024. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1144665233","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","1144665233","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","2019-09-01","842726","270548","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS   Eff 8/2024, Symplr will now manage. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2019-09-01","1144665233","","2024-07-08","Revalidation approved. Effective 09/01/2019. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2025-09-17"," 1144665233","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 09/17/2025 for all locations. PIN is the NPI."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","Pending Info/Document","2025-03-06","","","2025-03-06","3/6/2025 unable to reattested invalid UN/PW-dvineyard"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1144665233","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1144665233","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 3303866 - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-12-05","","","2024-09-09","Provider is linked to this location. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","1144665233","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","","","2025-07-15","Received confirmation via email from Brandy Smith provider participating effective 9/1/2020. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2020-09-01","6694913","","2025-08-08","08.04.2025 JB: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Enrollment Complete","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2019-09-01","Q00007922","DU2795","2025-02-20","Confirmed Enrollment. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2019-07-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc.","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02","1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15","1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-05","","","2023-10-20","10/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-07-01","5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","7585417","","2025-08-11","08.05.2025 JJ: Called Cigna @ 1-800-882-4462 to obtain FU status of the provider and s/w Angela. Per rep, provider is in-network and linked to TIN with eff date 06/05/2023. PIN: 7585417. Physical location is on file. Call ref#: Angela H. 08/05/2025."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-08-11","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc.","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc.","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-14","1932541406","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","397298601","079837301","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-21","1932541406","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-05","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2022-03-11","","","2025-09-15","Received email notification (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/ Location effective 3/11/2022. ML"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","1528619525","","2024-08-21","Revalidation Approval Ltr rcvd. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-04-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-05","14530139","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1528619525","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","403199901","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","1528619525","","2025-03-17","Per TMHP, license has been updated and Megan is showing active again. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312274","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11","1528619525","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","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","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-10-01","869041","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-09-01","","","2025-08-12","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Kristen. Per rep, NPI# is on file for the provider and is participating effective 09/01/2024 under the group and TIN#. Physical location is on file. Provider ID is 6345073. Call ref# 256064729."]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01","09832854","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1528619525","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-07-27","IMS complete"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 12/30/2019.  DCannon"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-02","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13","1528619525","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-14","1922658319","","2025-12-11","Per Den A. at Aetna ref#293573427. 4214 Andrews Hwy and 400 Rosalind Redfern Grover Pkwy have been added to provider effective 11/14/2024. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-14","1922658319","","2025-12-11","Per Den A. at Aetna ref#293573427. 4214 Andrews Hwy and 400 Rosalind Redfern Grover Pkwy have been added to provider effective 11/14/2024. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-14","1922658319","","2025-12-11","Per Den A. at Aetna ref#293573427. 4214 Andrews Hwy and 400 Rosalind Redfern Grover Pkwy have been added to provider effective 11/14/2024. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-14","1922658319","","2025-12-11","Per Den A. at Aetna ref#293573427. 4214 Andrews Hwy and 400 Rosalind Redfern Grover Pkwy have been added to provider effective 11/14/2024. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26.ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2022-08-28","1922658319","","2025-12-17","Submitted address changes. Request 3 20853698 VA"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 709 W Louisiana Ave/1805 S County Road 1105/4214 Andrews Hwy Suite 103/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Ana Maria Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana Maria Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-26","14485629","","2025-12-15","CAQH profile reattested by another user. All information up to date. Next attestation due on 3/17/26. ML"]
["Ana Maria Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13","","","2021-08-06","8/6/2021 Rcvd confirmation from Caprock that provider is par and linked to TIN/locations effective 10/13/2020.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","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","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 Denise Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2022-12-19","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 12/19/2022.  DCannon"]
["Stephanie Denise Crawford, FNP","1265081616","27-4061759","TX","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 Denise Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2022-12-19","","","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"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-02-11","1B4358","320497","2020-04-23","04/23/2020 - Found porivder as EFF under gorup enrollment through PECOS - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-04-01","7365931","","2020-09-08","09/08/2020 - Rec'd spreadsheet from the payer that confirms this provider is PAR with commercial 4-1-2020, community & state 4-1-2020 and Medicare 6-1-2020 products. This service location IS listed on file for this provider under this TIN. Moved to completed status using providers Unique UHC ID#  - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-06-01","1447882915","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 060/1/2020 for all locations. PIN is the NPI."]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-08-21","","","2025-12-08","CAQH Reattested. All information up to date.  Next attestation due on 4/7/26. ML"]
["Marlena Flores, CPNP","1215318092","75-2133441","TX","Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2025-09-03","","","2025-10-15","Per email from Aleece provider effective 9/3/25-SG"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-02-28","","","2025-05-12","Received email confirmation from Karen Avalos provider is participating, linked to TIN/location, eff.  2/28/2025. PA."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-04-08","","","2025-06-12","Approval ltr rcvd. Location added effective 04/08/24. Jen Videan"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-28","3961479","","2020-09-01","09/01/2020 - moved to completed status after getting an email from the payer stating \"Your effective date is 08/28/2020. Your provider identification number is 3961479. \" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","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"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-29","1750796009","","2020-04-16","04/16/2020 - Rec'd email spreadsheet confirmation from the payer stating this provider is linked to PRI MED DELEGATED agreement with all products under this TIN/Service location - Stacey Hudak\n\n**Verified the provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2022-02-10","12/10/2022 Per Tricare portal, provider is linked to location as of 12.8.2021. Cbankston"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","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"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","1750796009","","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"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1750796009","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2018-08-03","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 8/3/2018.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6186781","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 6186781  DCannon"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","1547832","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this providers demo update has been made - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1447701602","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer confirming this provider is affiliated with PRIMED DELEGATION under this TIN/Service LOcation. THis provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","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","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","3016142","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2017 PID # 3016142\ntisha rader"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2016-11-07","1154767234","","2020-09-09","09/09/2020 - Reviewed previous note and moved to completed status - Stacey Hudak"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1154767234","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1154767234","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-10-15","","","2025-08-13","08/06/2025 TE: Called 1-800-882-4462 and spoke with Ron at CIGNA. Provider is linked to TIN but service location is not on file. As per rep, to add the service location, send email to intake_pdm@evernorth.com with all the provider's information and W9. TAT 20-30 calendar days. Call ref# Ron 08/06/2025"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2015-08-29","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/29/2015.  DCannon"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1154767234","","2020-10-30","10/30/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Oct 7, 2020 12:05:19 PM. Your request was assigned reference number PR-5533533 .\" - Stacey Hudak"]
["Chabacana Maxwell, APRN-NP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-02-20","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/20/2019.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-08","1891931341","","2020-07-21","07/21/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 8, 2020 1:28:34 PM. Your request was assigned reference number PR-5374767 \" - Stacey Hudak"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","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","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/12021.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-08-25","1891931341","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-05-01","","","2022-04-13","4/13/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 5/1/2020.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-02-10","2/10/2022 Per Tricare portal, provider is linked to location as of 12.9.2021. Cbankston"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","TX","Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2022-06-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","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","ME","Midland Medicine PA","IMS","Participating","Enrollment Complete","2021-08-09","","","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 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","Midland Medicine PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Hagos Zeferu Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2019-09-01","6167866","","2020-06-29","06/29/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed. \n \nPID # 6167866\nHCP Name #  Hagos Aymut\nTIN # 475554737\nEffective Date # 09/01/2019\nCigna Internal Reference # W202006161088488\" - Stacey Hudak"]
["Hagos Zeferu Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","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","WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-24","5/1/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd.  and 6301 Andrews Hwy.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-12-21","12/21/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 10/4/2024. AS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 10/4/2024. AS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1528430865","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","1528430865","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","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","","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","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","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","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-30","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN and location, eff. 01/30/2019. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2020-04-15","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-12-01","1528430865","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2018 for all locations. PIN is the NPI."]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","1528430865","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-12-21","12/21/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/2/2023.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Jerry R. call ref 14076021, provider participating as of 8/1/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. mS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 7/01/20. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","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","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 10/1/2018.  PID # 715814.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1528430865","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1528430865","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-18","08/18/2025 AC: Called 800-882-4462 and spoke w Lysa at Cigna. Stated provider not PAR need to process over the phone for office based provider and for hospital based need to submit email through email at intake_pdm@evernorth.com. Call ref number Lysa T 08/18/2025"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","","Multiplan","Participating","Enrollment Complete","2020-06-10","1215575576","","2020-09-08","09/08/2020 - Rec'd email from the payer confirming this provider is EFF:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nJordan Elizabeth Friday, NP NPI: 1215575576\n5026 – West Texas Physicians Alliance – Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 06/10/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 06/10/2020\" - Stacey Hudak"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1215575576","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider's participation under group Tax ID effective 9/1/2020 and assigned PIN number 6314133. Kimberly Frazier"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2021-12-15","7406945","","2022-04-05","4/5/2022 Per email from UHC at networkhelp@uhc.com provider is PAR and linked to group TIN/location effective 12/15/2021.  MPIN # 7406945.  DCannon"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","14594087","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Satish Nayak, MD","1518053149","57-1157825","TX","Satish Nayak","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1518053149","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 1091293 - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","Omni PPO","Participating","Enrollment Complete","2023-07-15","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2023-07-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","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","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2020-11-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 11/1/2020. Kfrazier"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","","Medicaid","Participating","Enrollment Complete","2020-09-24","414415601","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 9/2/2020.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2021-01-01","","","2021-02-20","2/20/2021 Rcvd approval letter from MultiPlan for WesTexas OrthoPedics providers effective 1/1/2021.  DCannon"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2019-12-13","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/13/2019 and link under the Group and TIN. Provider ID 2343457.  Service location is on file. Call ref#:610334. DCannon"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2020-01-01","1225277833","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-06-05","","","2025-06-05","06/05/2025 CAQH Reattested-all information is correct and up to date. I was unable to pull BC doc-dvineyard"]
["Carlos Molina, DO","1225277833","75-1997880","TX","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"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2019-12-13","","","2023-05-02","5/2.2023 Per confirm par status - Per rep, provider is showing participating with an effective date 12/13/2019 and link under the Group and TIN. Provider ID 2343457.  Service location is on file. Call ref#:610334. DCannon"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","USA PPO","Participating","Enrollment Complete","2017-04-03","1225277833","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","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","Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2009-03-16","P02539434","DS7320","2020-10-29","10/29/2020 - Rec'd confirmation of effective enrollment from the payer portal - Stacey Hudak"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727806","","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"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","Medicare","Participating","Enrollment Complete","2021-01-01","1M9244","","2021-04-26","4/26/2021 Per Stacy Salazar she processed provider's enrollment application and assigned PTAN is 1M9244, effective 1/1/2021. KFrazier"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","Aetna","Participating","Enrollment Complete","2020-09-16","9363366","","2025-08-11","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Kristen. Per rep, NPI# is on file for the provider and is participating  under the group and TIN#. Physical location is on file. Provider ID is 9363366. Call ref# 256064729."]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2019-08-30","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 11/01/2019 for Commercial Choice, 08/02/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2010-01-15","1669617981","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2015-01-01","6837080","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-05","1972073906","Contract Source Individual","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","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"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-05-27","","","2025-08-11","08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id effective 05/27/2021.Provider id# 8559734.Physical location is onfile.Call ref# Sophia C 08/05/2025."]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","Alliance WC","Participating","Enrollment Complete","2021-05-21","1780078089","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 75-2656723. Cbankston"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-03-29","1720353592","","2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2020-07-11","1720353592","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2020-07-13","1184035313","","2020-10-23","10/23/2020 -Called the payer and spoke with Corrine and was told that this provider HAS BEEN DE-DELEGATED AS OF 6-19-2020 and currently holds a direct contract with UHC. Provider is linked to this TIN as of 7-13-2020. - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","2020-08-22","N/A RHC","112273103","2020-09-28","09/28/2020 - Rec'd email from the payer stating this in an RHC - through facility only, no provider enrollment. OK to move to done status. - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-07-01","1184035313","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","Andrews County Hospital District","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","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2022.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","Permian Physician Services","Molina","Participating","Enrollment Complete","2020-04-17","1306928098","","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","","Multiplan","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2016-04-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 4/1/2016.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2024-05-21","1306928098","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1184626749","","2020-08-21",""]
["Paul Slaughter, DO","1184626749","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","1184626749","","2020-09-24","09/24/2020 - moved to completed status and found this provider has a direct contract EFF - Stacey Hudak"]
["Maria Montero, MD","1508218843","75-2656723","TX","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","North Big Spring Family Care","Medicare","Participating","Enrollment Complete","2020-09-09","1G8516","0008AH","2020-09-15","09/25/2020 - Rec 'd email from this payer to be EFF and linked to this group - Stacey Hudak"]
["Maria Montero, MD","1508218843","75-2656723","TX","North Big Spring Family Care","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2014-06-30","1205392","","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"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-08-12","\"08.06.2025 KF: Called First Health Coventry @ 800-226-5116 and spoke with Ali. Provider is in network and link to TIN effective 10/01/2024. Location is on file. PIN is 3986181. Call ref# 1671071\n\""]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","Omni PPO","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"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-09-17","","","2024-12-26","Received email from Erica Lee, confirming location update completed. Location added to provider's profile, using initial cred date as eff. date: 9/7/2020. PA."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-12","1720111883","","2025-08-11","08/04/2025 KC: Called 1-800-353-1232 and spoke w Frances M at Aetna. Stated provider is innetwork and link to the tax id effective 11/12/2024.Provider id# 9212791.Physical location is onfile.Call ref# 255600156.Called again Aetna and spoke w/ Liz P per rep aetna payer # is 60054.Call ref 255654594"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-10-24","4138818","","2025-02-04","Received welcome email. MS"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","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"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312371","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","No Enrollment Required","Payor Follow Up","","","","2025-06-04","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13","","","2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","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"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-12-07","","","2021-08-01","8/1/2021 Per Mary Rodriguez w/ Caprock provider is PAR and linked to group TIN/locations effective 12/7/2020.  DCannon"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1291204","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  9/2/2021. DCannon"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-08-18","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","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"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-09-05","","","2025-09-05","09/05/2025 CAQH Reattested-updated TX Lic exp and uploaded doc-dvineyard"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","Permian Gastroenterology PA","Aetna","Participating","Enrollment Complete","2023-06-15","6761851","","2023-12-27","12/27/23 Per Follow-Up note - Provider is in network with Aetna for the state of TX and linked to the group and TIN# effective 06/15/2023. No next recredentialing date available. PIN: 6761851. Servicing location is on file. DCannon"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","Permian Gastroenterology PA","Cigna","Participating","Enrollment Complete","2023-09-01","3330657","","2023-10-31","Received confirmation email.. MS"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","Permian Gastroenterology PA","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2025-08-04","","","2025-09-18","Per email from Addella, provider effective 8/4/25. SG"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-01","4/1/2021  Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-10-01","","","2025-09-16","Received email notification from Karen Avalos (kavalos@ghn-mci.com) confirming provider's participation with network under TIN/ Location effective 10/1/25. ML"]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2025-10-01","","","2025-10-10","per email from Mindy provider eff 10/01/25-SG"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-01-06","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 01/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1861504987","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ 3490 E Yukon Rd./  Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1861504987","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ 3490 E Yukon Rd./  Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-01-01","7F4080","423838","2025-02-03","Provider has been added to the group record. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-01-01","7F4080","423838","2025-05-01","Provider is linked to both group TIN's. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-01-01","Q00961273","DX4335","2025-02-20","Confirmed enrollment. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-01-01","Q00961273","DX4335","2025-02-20","Confirmed enrollment. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-03-01","1861504987","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2025 for all locations. PIN is the NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-01-15","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 1/15/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-01-15","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 1/15/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-04-16","1861504987","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 4/16/2025 for all locations. NPI# is PIN."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-01-06","","","2025-03-24","Received email confirmation provider is PAR, linked to TIN/location, eff. 1/6/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2008-11-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 11/1/2008. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-02-14","1861504987","","2025-02-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-01-06","","","2025-01-28","Received confirmation via email from Emily Starr that provider is participating. AS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-01-06","","","2025-01-28","Received confirmation via email from Emily Starr that provider is participating. AS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-02-06","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/locations, eff. 02/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-30","Received confirmation via email from TexasNetwork@LibertyMutual.com, provider participating eff date 7/1/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-27","1861504987","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-27","1861504987","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-01-15","","","2025-01-31","Received confirmation via email from Angela Bates, provider participating as of 1/15/2025 with Blue Choice PPO, Blue Advantage HMO, Blue Essentials HMO, Health Select, Medicare Advantage PPO. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-01-06","","","2025-04-14","Received email from Karen Avalos confirming January roster was processed. Provider par, eff. 01/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd./ 5514 N Big Spring St 08/05/2025 KN: Called Cigna@1-800-882-4462 and spk w/ Jessica. Per rep, provider is OON under the Grp/TIN and state of TX however the TIN 47-3465832 is contracted under Ancillary Contract. Rep advised that Cigna does not add individual provider to Ancillary contract so there's no need to submit app for the provider and we can just bill claim under the Name of the Grp. Rep can't provide eff date of the Grp Ancillary Contract unless service address on their file is verified. Service Address we have is not on file and per rep, we need to add it to the Grp Ancillary Profile since we need to ensure that before we bill a claim, service address is added to the In Network location list of the Grp. Per rep, submit LOI and W9 Form through email intake_pdm@evernorth.com. Subject: 2 Letter Abbreviation of State, Group Name, TAX ID# (Make sure no dash on TAX ID), Concern. TAT is 30 cal days from received date. Callref: Jessica S 08/05/25"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd./ 5514 N Big Spring St 08/05/2025 KN: Called Cigna@1-800-882-4462 and spk w/ Jessica. Per rep, provider is OON under the Grp/TIN and state of TX however the TIN 47-3465832 is contracted under Ancillary Contract. Rep advised that Cigna does not add individual provider to Ancillary contract so there's no need to submit app for the provider and we can just bill claim under the Name of the Grp. Rep can't provide eff date of the Grp Ancillary Contract unless service address on their file is verified. Service Address we have is not on file and per rep, we need to add it to the Grp Ancillary Profile since we need to ensure that before we bill a claim, service address is added to the In Network location list of the Grp. Per rep, submit LOI and W9 Form through email intake_pdm@evernorth.com. Subject: 2 Letter Abbreviation of State, Group Name, TAX ID# (Make sure no dash on TAX ID), Concern. TAT is 30 cal days from received date. Callref: Jessica S 08/05/25"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-06","","","2025-08-06","08/06/2025 CAQH Reattested-updated TX Lic exp and uploaded doc and updated Cred Cont-dvineyard"]
["Amanda Compton, MD","1679953517","75-1997880","TX","","Sedgwick","Participating","Enrollment Complete","2024-04-17","1679953517","","2024-04-29","Rcvd acceptance letter. Provider effective 04/17/2024. Jen Videan"]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-04-06","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Amanda Compton, MD","1679953517","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2021-07-08","","","2024-02-28","Re-Cred has been completed. eff 7/8/2021. MS"]
["Amanda Compton, MD","1679953517","75-1997880","TX","Andrews County Hospital District","Medicaid","No Enrollment Required","No Enrollment Required","2021-04-01","","","2021-04-08","4/8/2021 Enrollment is not required due to practice being an RHC. KFrazier"]
["Amanda Compton, MD","1679953517","75-1997880","TX","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-13","","","2021-08-30","8/30/2021 Rcvd email from Scott & White (First Care) <SWHPDELEGATION@BSWHealth.org>that provider is PAR and linked to group TIN/locations effective 5/13/2021.  DCannon"]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","Cigna","Participating","Enrollment Complete","2022-12-01","2149846","","2023-01-31","1/31/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 2149846.  DCannon"]
["Amanda Compton, MD","1679953517","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2021-04-05","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 4/5/2021.  DCannon"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2021-07-09","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/9/2021.  DCannon"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete","2023-12-11","1427540","","2024-01-02","Received confirmation of approval effective 12/11/2023. MS"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","Debbie P. Reese, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-11","","","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 12/11/2023.  DCannon"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","In House Enrollment","2021-08-01","Q00109888","CE1588","2021-08-03","8/3/2021 Rcvd RR Medicare approval letter from Candace Wynn.  DCannon"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2021-08-09","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1851865067","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","1851865067","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 10/08/2021.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-09-01"," 1851865067","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-19","Eastridge eff 10/9/23, Briarwood eff. 10/9/23 and Longview eff. 7/10/21 locations are all approved. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","Tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","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","","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"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2022-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/01/2022. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-01","","","2023-09-08","Provider is currently enrolled with all locations under WesTex. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-09-01","1851865067","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2024-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","3642314","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 05/01/2023. Next recredentialing date is on 05/01/2026. PIN: 3642314. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Application Resubmitted","2023-05-01","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-24","Re-Cred completed. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2021-11-13","","","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","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-12-08","CAQH profile reattested, all information up to date. Next attestation due on 4/7/26. ML"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 05/01/2023, and linked to 616 Main St. location. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3578768","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","1851865067","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","1851865067","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1851865067","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 09/01/2021.   PA"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-04-18","1851865067","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 4/17/2024 for all locations. NPI# is PIN."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-13","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 11/13/2021. PA."]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","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","Sandra Maerzacker, MD, PLLC","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2023-06-21","Rcvd effective date of 08/13/2021 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-11-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-05","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-12","Q00306920","CE1588","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # Q00306920 - effective 7/12/2022.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Add Info Submitted","2021-11-01","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2022-04-05","","","2022-04-21","4/21/2022 Per email received from Ryan Gardner at Multiplan provider is PAR and linked to group/location effective 4/5/2022.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-10-21","4000052","","2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/21/2021 under the group and TIN#. PIN 4000052. Physical location is on file. Call ref# Roberts10272021."]
["Addis Getahun, MD","1548765183","47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2021-10-21","Q00162940","DW7662","2021-11-12","11/12/2021 Rcvd RR Medicare PTAN via online RR Medicare portal.  PTAN # Q00162940 - effective 10/21/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Add Info Submitted","2023-09-01","3733859","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","75-2656723","TX","","USA PPO","Participating","Payor Follow Up","2025-09-01","","","2025-08-15","Requested enrollment status via email, sent to payor. ML"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-11-01","","","2022-05-19","5/19/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2021-10-29","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2025-09-01","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 09/01/2025. PA."]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","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","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-09-27","6663751","","2022-06-22","6/22/2022 Per email received from UHC with a roster attached provider is PAR and linked to group TIN/locations effective 9/27/2021.  MPIN # 6663751.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-11-01","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 11/1/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-11-25","","","2021-12-13","12/13/2021 Rcvd email from UHC that provider is PAR and linked to group TIN/location effective 11/26/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","","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","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"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-12-15","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/location effective 12/15/2021.  DCannon"]
["Fukamanji Sikazwe, FNP","1821679051","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2025-12-17","Cannot start the Medicare application until next year due to waiver. VA"]
["Fukamanji Sikazwe, FNP","1821679051","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2025-12-17","Cannot start the Medicare application until next year due to waiver. VA"]
["Brandon Henry Rayne, PA","1912482209","46-0950925","TX","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 Henry Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2024-08-19","As per Cassandra Dunagon received confirmation provider participating as of 5/1/2023 via email. FC"]
["Brandon Henry Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna","Participating","Enrollment Complete","2023-11-08","4813053","","2023-11-14","Received confirmation email. MS"]
["Judy J Jia, MD","1588983134","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2023-03-12","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Judy J Jia, MD","1588983134","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Judy J Jia, MD","1588983134","75-2656723","TX","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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Judy J Jia, MD","1588983134","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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","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","","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-21","9373023","","2022-03-30","3/30/2022 Received email from pdmcogz@cigna.com, provider is par as of 2/21/2022, PID: 9373023. This request has been completed under Cigna Internal Reference#: W202203222253423. Cbankston"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-23","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/23/2022.  DCannon"]
["John H Ownby, MD","1558343988","75-2656723","TX","","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"]
["John H Ownby, MD","1558343988","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"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267339","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q0267339 - effective 2/21/2022.  DCannon"]
["Megan E Rosa, PA","1720698640","46-3131679","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2025-11-30","","","2025-11-17","Broadspire application has been approved effective 11/30/25 per Olivia Stovall. VA"]
["Megan E Rosa, PA","1720698640","46-3131679","TX","Midland Texas Orthopedic Group Inc","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress case#18966893. MR"]
["Megan E Rosa, PA","1720698640","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1720698640","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-10-07","","","2025-01-29","Received confirmation via email from Caprock rep, provider participating as of 10/7/2024. FC"]
["Megan E Rosa, PA","1720698640","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2025-11-30","","","2025-12-01","Application has been approved effective 11/30/2025. Reference # 3253140724 VA"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-09-03","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 9/3/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","","Omni PPO","Participating","Re-Credentialing","2022-07-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-07-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 7/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2022-04-14","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing","2022-05-09","6757971","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2022-05-09","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of  05/09/2022. PA."]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Confirm Par Status","2022-04-14","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 04/14/2022.  PA."]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No action provider will need to complete initial credentialing prior to adding CCN. Please resubmit your request to add CCN once provider has fully Initial Credentialing.\""]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","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"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","","IMS","Participating","Re-Credentialing","2022-05-09","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1720698574","","2024-06-28","Approval ltr rcvd. Provider eff 06/19/2024. Jen Videan"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Confirm Par Status","2022-04-20","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of  04/20/2022. PA."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Add Info Submitted","2022-05-09","007929415","","2025-07-15","Submitted request to update phone/fax #'s for each location via delegated roster submission. PA."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Add Info Submitted","2022-05-09","007929415","","2025-07-15","Submitted request to update phone/fax #'s for each location via delegated roster submission. PA."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","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","Premier Texas Kidney Care, PLLC","Superior","Participating","Add Info Submitted","2022-08-01","","","2025-07-15","Submitted primary practice and mailing address update (1809 Middleton St) to payor per request. PA."]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Scott&White (First Care)","Participating","Add Info Submitted","2022-08-15","","","2025-07-15","Submitted primary practice and mailing address update (1809 Middleton St) to payor per request. PA."]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","Premier Texas Kidney Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-20","","","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 6/20/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Medicaid","Participating","Enrollment Complete","2022-05-01","","","2024-01-31","Provider was added during group enrollment. Provider is active with Medicaid, effective 05/01/2022. Jen Videan"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","2024-06-04","","","2025-01-29","1/29/2025 per email from Priscilla on 1/29/2025 providers CAQH is maintain by group-dvineyard"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-18","9368747","","2022-10-25","10/25/2022 Rcvd approval notification email from Cigna.  Provider is PAR and linked to group TIN/location effective 7/18/2022.  PID # 9368747.  DCannon"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2025-07-08","","","2025-09-08","Received notification via online chat box (spoke with Derek, ref. # 05415338) confirming provider's participation with network effective 07/08/2025. ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02","Received confirmation via email from provider_services_shared.t8@90degreebenefits.com, provider participating eff 7/8/2025. FC"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2025-03-05","0939080","","2025-06-02","Provider has been approved and linked. MS"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","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"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","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"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-06-02","1598260325","","2023-06-09","confirmed via the website directory the provider is active. MS"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-23",""]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-09-19","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/19/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-26","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2022-09-26","","","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 9/26/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Omni PPO","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","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","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1285983155","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd  confirmation that provider is PAR in Superior Health plan under the group TIN effective 2/1/2023.   DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-10-31","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/31/2022.  PID# 14835000.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","5935530","","2023-09-21","09.21.2023 S/W Dennisse of Cigna @ 1-800-882-4462. Per rep, provider is part of a behavioral program then rep advised to call the behavioral dept at 800-274-4573. Called Cigna's behavioral dept @ 800-274-4573 then S/W Heba. As per rep, provider is showing participating and link under the Group and TIN with an Effective date 02/02/2023. Provider ID 5935530. Service location is on file. Call ref#:HebaH09212023. - Danico Gabriel Melendres"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-10-31","","","2022-12-29","12/29/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Per tricareproviderinquiries@triwest.com, no active contract. Jen Videan"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-10-31","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-31","","","2022-11-21","11/21/2022 Rcvd email from Caprock that November Delegation roster provider load has been completed.  Provider is PAR and linked to group effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-12-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-10-31","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.   DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-10-31","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-24","Tricare Prime panel is closed. MS"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete","2023-12-11","8365374","","2024-01-02","Received confirmation of approval. MS"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","IMS","Participating","Enrollment Complete","2023-12-11","","","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 12/11/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-06-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  06/01/2023.  PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-02-01","4920546","","2024-03-19","Received email confirming enrollment. MS"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-02-10","Q00724982","","2024-04-25","Received confirmation of enrollment. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Delegated - Third Party","","","","2024-01-31","Check Coventry portal for enrollment updates. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","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","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","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-21","","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-21","","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-03-31","3671302","","2023-09-20","09.20.2023 S/W Kivon of First Health @ 800-226-5116 and transferred me over to Marva. Per rep, provider is in network with First Health and linked to the group and TIN# effective 03/31/2023. No next recredentialing date available. PIN: 3671302. Servicing location is on file. No payer# available. Call ref# 760853. - Willie Ravas"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 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","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","Tx","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","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","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2023-06-26","007726107","","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","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","1538714076","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","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","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-05","1538714076","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 10/18/2023 for all locations. PIN is the NPI."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2024-07-19","Received roster from HP Delegation; provider is shown linked to TIN/locations, eff. 05/14/2023. PA."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-03-31","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 3/31/2023, and linked to 616 Main St. location. PA."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-05-15",""]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-17","2V9975","","2023-08-25","Per PECOS provider is PAR and linked to group/locations effective 3/17/2023.  PID # 2V9975.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-26","00726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1538714076","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1538714076","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","IMS","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Molina","In Process","Payor Follow Up","","","","2025-12-02","Emailed mhtcontractrequest@molinahealthcare.com along with W9 for enrollment process, Molina stated they did not have the original request. FC"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2017-06-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/2/2017.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","","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","","Cigna","Participating","Enrollment Complete","2023-11-15","","","2024-12-05","Received confirmation of enrollment. W202411154391260  MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","","Boon Chapman","No Enrollment Required","No Enrollment Required","2023-06-01","","","2025-02-28","Boon Chapman is a 3rd party insurance who is under several networks such as Aetna, Cigna, 1st Health, Multiplan or PHCS network. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-04-14","9695700","","2023-10-19","10.16.2023 S/W Cob of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 04/14/2023. Provider ID 9695700. Service location is on file. Call ref#:6166953623.-Danico Gabriel Melendres"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 07/20/2023. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-30","","","2024-04-25","4/25/2024 provider enrolled as of 6/30/2023 via roster. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1518292077","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1518292077","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 6/1/2023. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","","IMS","Participating","Enrollment Complete","2023-10-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-06-12","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","","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","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-08-25","1518292077","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Kelly Burrows, FNP","1518292077","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","1518292077","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","1518292077","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","1518292077","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd 5/21/2024\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 6/12/2023. AS"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-06-12","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 06/12/2023. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-08-01","1518292077","","2025-08-27","08/27/25 MQ: For Locations: 6301 Andrews Hwy/4705 Briarwood Ave/6950 Eastridge Rd./ Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/01/2023 for all locations. PIN is the NPI."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","1518292077","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 8/21/2024 for all locations. NPI# is PIN."]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1518292077","","2025-09-09","09/09/2025 AC: For location: 6301 Andrews Hwy/ 4705 Briarwood Ave/ 6950 Eastridge Rd. Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1518292077","","2025-09-09","09/09/2025 AC: For location: 6301 Andrews Hwy/ 4705 Briarwood Ave/ 6950 Eastridge Rd. Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-12-08","CAQH profile reattested. All information up to date. Next attestation due on 4/7/26. ML"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Travelers WC","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Sedgwick","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","","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2024-01-24","Provider has been loaded to this location. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Superior","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Texas Municipal League","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"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-25","","","2023-09-20","9/20/2023 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 9/25/2023.  DCannon"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","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","","Aetna","Participating","Add Info Submitted","2023-09-08","7585624","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-08-24","Confirmed via Tricare portal. MS"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","Midland Pediatric Associates, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","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","","Cigna","Participating","Enrollment Complete","2023-11-14","8664168","","2023-11-17","Received confirmation email from payor. MS"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-09-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","Omni PPO","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-09-19","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-09-19","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","TriWest HC Alliance","Participating","Payor Follow Up","2023-08-24","6859498","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","Triwest VA","Participating","Enrollment Complete","2024-02-15","","","2024-02-21","Received confirmation provider is par w/ Triwest VA per email from Scarlett Abigail, eff. 02/15/2024. PA."]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","Amerigroup","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","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","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","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","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","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-08-22","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Add Info Submitted","2023-09-08","3746322","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","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","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-03","3871534","","2023-11-06","Received welcome email eff 11/3/23. MS"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Abbie Estes, PA","1952088411","46-0950925","TX","","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"]
["Abbie Estes, PA","1952088411","46-0950925","TX","","Omni PPO","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2023-09-08","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","","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"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","1952088411","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2020-07-20","1376006403","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","08.06.2025 KF: Called Cigna @ 1-800-882-4462 and spoke with Paul. Per rep, provider is OON. To be credentialed and par, rep advised to send an email to psscentral@cigna.com. TAT is 60 cal days. Call ref# Paul C08062025"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new providers at this time. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","1376006403","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-30","1376006403","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1376006403","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd eff. 5/21/2024\n616 N Main St. & 4705 Briarwood Ave  eff. 9/8/2023. AS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-30","1376006403","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is the NPI. Loc is not on file."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-20","1376006403","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/20/2023 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376006403","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2020-07-20","1376006403","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-21",""]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-11","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","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","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","Midland Inpatient Medical Association","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","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","Premier Family Care, Inc","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-08","","","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 11/8/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff.  11/06/2023 and linked to TIN. PA"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","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"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","","","","2024-03-07","3/7/2024 Received Wellpoint roster, provider showing effective 12/4/2023. FC"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","","First Health Coventry","Participating","Add Info Submitted","2024-01-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2023-12-06","6700596","","2024-02-14","Received welcome email. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","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","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-09-28","Provider is enrolled with the Florida location effective 9/25. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-29","8412605","","2023-12-06","Received confirmation email of approval effective 11/29/23. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Per tricareproviderinquiries@triwest.com, no active contract. Jen Videan"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","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"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-02-05","Confirmed provider is enrolled eff 10/1/2023. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-07-01","Main St. location approved 6/10/24. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-03-11","","","2025-03-12","Received confirmation via email, provider participating as of 3/11/2024. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St. 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is totally OON and not link to the tax id.To be innetwork/credentialed rep advised provider must reach out cigna to initiate the application over the phone/call.TAT 60 cal days.Call ref# Jaq A 08/05/2025."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","","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"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","1790315737","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","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 except Longview location. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-01-24","00390311","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  01/24/2024.  PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-01-24","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  01/24/2024.  PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2024-01-24","008766524","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  01/24/2024.  PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","1790315737","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/21/2024 for all locations. PIN is the NPI."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","1790315737","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 11/06/2023. PA"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2024-02-05","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Neel N Shah, MD","1861752529","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-04-09","Received email on 4/8/24 provider is PAR, eff. 3/1/2024. PA."]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-03-21","03/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com), provider is PAR, eff. 02/05/2024. PA"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-03-19","Sent email to delprov@uhc.com requesting update on enrollment status. PA"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00615975","","2023-12-07","Received approval letter. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","IMS","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 except Longview location. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","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","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","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."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-16","Payor has closed the enrollment panel until further notice. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-29","","","2025-10-30","CAQH profile reattested - COI Updated - Information up to date - Next attestation due on 2/27/26. ML"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-29","","","2025-10-30","CAQH profile reattested - COI Updated - Information up to date - Next attestation due on 2/27/26. ML"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","1841508462","","2024-01-05","Welcome letter rcvd. Provider effective 12/15/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is OON. To enrolled this provider that will be over the phone #8002446224. TAT 60CD. Call Ref#AbyS08052025."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","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","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","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","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 616 N Main participating as of 2/1/2024. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-03-20","1841508462","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 3/20/2024 for all locations. NPI# is PIN."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 11/06/2023. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","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"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-01-19","1376149153","","2024-01-29","Alliance WC approval letter rcvd. Provider effective 01/19/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376149153","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is not on file. PIN is NPI."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently listed. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Payor Follow Up","2024-01-04","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN and following locations: 616 N Main St, 4705 Briarwood, and 6301 Andrews HWY, eff. 1/04/2024.  Need remaining locations linked. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is not credentialed, out of network. Rep advised to have an over the phone application or send it via email at psscentral@cigna.com. TAT 60 calendar days. Call ref# Jay 08/06/2025"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-12-04","","","","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-22","","","2023-11-27","11/27/23: Received confirmation from BCBSTX per email, provider enrolled with the following networks, eff. 11/22/23:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-21","","","2024-05-28","Spoke to Irish call ref#6193526649 all four location participating as of 5/21/2024. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024 Spoke to Schicka call ref#619284276, 616 N Main St location participating as of 2/1/2024. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-01","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-01","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  11/01/2023.  PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 12/4/2023\n3490 E Yukon Rd eff. 9/1/2024. AS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 12/4/2023\n3490 E Yukon Rd eff. 9/1/2024. AS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-11-01","Q00771231","DX4335","2024-06-26","Enrollment welcome letter received. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-11-01","Q00771231","DX4335","2024-06-26","Enrollment welcome letter received. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376149153","","2025-09-08","09/08/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy. Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-12-01","1376149153","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2023 for all locations. PIN is the NPI."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-11-01","6E0916","","2023-11-29","Received approval letter effective 11/1/2023. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-03-11","","","2024-05-29","As per Kodi from IMS, provider participating as of 3/11/2024 received via email. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-02-27","","","2024-04-29","ReCredentialing has been completed eff 2/27/24. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2024-03-11","","","2024-05-29","As per Kodi from IMS, provider participating as of 3/11/2024 received via email. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2024-03-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-23","","","2024-05-23","Received email confirmation (from hpregion3@bswhealth.org) provider is PAR, eff. 4/15/2024, and linked to TIN/location. PA."]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-01-08","1922875160","","2024-03-06","Confirmed enrollment via provider directory. MS"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-15","","","2025-11-25","Spoke to Desahwn B at 800-226-5116, provider eff date 1/15/2024, call ref#1830438. FC"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-02-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 02/01/2024. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","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","","Amerigroup","Participating","Application Resubmitted","2024-02-05","","","2025-01-15","Application resubmitted via delegated roster. AS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","","","","2024-01-09",""]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-15","","","2024-04-29","Provider's recert has been approved eff 1/15/2024. MS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2024-02-05","","","2025-01-15","Application resubmitted via delegated roster. AS"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2024-02-23","1912697970","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Payor Follow Up","","","","2025-12-02","Emailed mhtcontractrequest@molinahealthcare.com along with W9 for enrollment process, Molina stated they did not have the original request. FC"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Add Info Submitted","2024-03-15","","","2025-03-14","Submitted TPI to payor via delegated roster. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-12-20","Q00681835","DU5783","2024-03-06","Provider is enrolled. MS"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2024-08-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 8/5/2024.  PA"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-02-10","Received confirmation via email from LaNetrice Myart, provider participating as of 9/13/2024. FC"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","","2098589","","2024-09-12","Received notice the provider is active and update has been made. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 9/9/2024. AS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 9/9/2024. AS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Cigna","Participating","Enrollment Complete","","2098589","","2024-09-12","Received notice the provider is active and update has been made. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-08-23","No enrollment needed. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-21","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2024-09-09","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 9/9/2024.  PA"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-07-01","Q00774557","CE1588","2024-07-01","Provider has been approved and linked. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-28","1184490161","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is not on file. PIN is NPI."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, 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","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-05","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  04/05/2024.  PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-03-06","6M4476","","2024-03-25","Received approval. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-03-07","1184490161","","2025-09-08","09/08/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St. Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 2/1/2025. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 2/1/2025. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024. AS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-13","For Locations: 6950 Eastridge Rd./6301 Andrews Hwy/ 616 N Main St./4705 Briarwood Ave 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is not credentialed, out of network. Rep advised to have an over the phone application or send it via email at psscentral@cigna.com. TAT 60 calendar days. Call ref# Jay 08/06/2025"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-05-20","5/20/2024- Spoke to Max C call ref# 6192813282 provider participating with all 5 locations effective as of 4/5/2024, provider listed as a SPEC. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 4/5/2024. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","1184490161","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 07/17/2024 for all locations. NPI# is PIN."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-04-05","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 4/5/2024 with all 5 locations. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-04-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-04-05","","","2024-05-29","Provider participating as of 4/5/2024 received via email from Kodi Kox. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-05","","","2024-05-09","Received confirmation from HPDelegation provider is PAR & locations linked, eff. 05/05/2024."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","1184490161","","2024-04-22","Approval ltr rcvd. Provider effective 04/12/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","1184490161","","2024-04-22","Approval ltr rcvd. Provider effective 04/12/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-04-12","","","2024-04-22","Please see status updates under Alliance WC payor line. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-28","1184490161","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-03-01","","","2024-07-31","Received email confirmation provider is par and linked to location, eff. 3/01/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","1184490161","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 07/17/2024 for all locations. NPI# is PIN."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Texas Mutual","Participating","Enrollment Complete","2024-09-01","1295354264","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 09/01/2024 for all locations. PIN is the NPI."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-10-01","","","2025-01-28","Received email confirmation provider is par, linked to TIN/location, eff. 10/01/2024. PA."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2024-09-15","","","2024-09-03"," Received email confirmation, provider is par, eff. 09/15/2024. PA."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Alliance WC","Participating","Enrollment Complete","2024-06-28","1295354264","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-09","Received Oct. validation report from SHP. Provider is listed par and linked to TIN/location, eff. 10/01/2024. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2024-06-10","","","2024-08-19","Per Humana rep, Rachel D, 1-800-448-6262, ref# 2000402330573, provider is linked to TIN and location, eff. 6/10/2024. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1669755906","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-05-06","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 05/06/2024.  PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  05/01/2024.  PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","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","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","Tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","1548026099","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-08","1548026099","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-05-06","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 05/06/2024.  PA"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new enrollments at this time. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","08.05.2025 JJ: Called Cigna @ 1-800-882-4462 to obtain FU status of the provider and s/w Angela. Per rep, provider is totally out of network with Cigna. Rep advised over the phone application or submit an application request (indicate all the provider's info) to psscentral@cigna.com. No required format in subject line, we can just put credentialing. TAT: 60 calendar days. Call ref#: Angela H. 08/05/2025."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6950 Eastridge Rd,  6301 Andrews Hwy 10/4/2024.\n616 N Main St, 4705 Briarwood Ave 5/6/2024\nAS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","For Locations: 6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./08.05.2025 JJ: Called Cigna @ 1-800-882-4462 to obtain FU status of the provider and s/w Angela. Per rep, provider is totally out of network with Cigna. Rep advised over the phone application or submit an application request (indicate all the provider's info) to psscentral@cigna.com. No required format in subject line, we can just put credentialing. TAT: 60 calendar days. Call ref#: Angela H. 08/05/2025."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","","","2024-10-29","Received confirmation via deleagted roster from Brandy Smith Provider participating effective 05/06/2024. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","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"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","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","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1548026099","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-10-30",""]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 7/17/2024 for all locations. PIN is the NPI."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 7/17/2024 for all locations. PIN is the NPI."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","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","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","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1093796435","","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"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","1093796435","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/12/2024. PIN is the NPI. Loc is not on file"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1093796435","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/26/2024. PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","8016068","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  05/01/2024.  PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","Tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1093796435","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1093796435","","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"]
["Teresa L Callahan, NP","1093796435","47-3465832","Tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 06/06/2024. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. Requested roster listing locations linked to provider via email. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main St., 6301 Andrews Hwy, 6950 Eastridge Rd., 4705 Briarwood Ave eff. 10/4/2024. AS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-07-31","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","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","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"]
["Rizwan Asim, MD","1205287646","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 11/01/2024. PA."]
["Rizwan Asim, MD","1205287646","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2025-08-27","","","2025-08-11","Provider revalidation application was approved with a effective date of 08/08/2025-08/26/2030. MR"]
["Rizwan Asim, MD","1205287646","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 10/07/2024. PA."]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 9/9/2024. AS"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2024-10-01","9619640","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/1/2024. FC"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","","Medicaid","Participating","Application Submitted","2024-06-26","1285863753","","2025-08-07","Revalidation application submitted req#20756568. MR"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2024-10-07","","","2025-03-12","Received confirmation via email, provider participating as of 10/7/2024. FC"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 10/07/2024. PA."]
["John W Romeo, MD","1447661764","47-5554737","TX","","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 10/7/2024. FC"]
["John W Romeo, MD","1447661764","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-02-05","Received confirmation via phone, provider participating as of 10/1/2024, call ref#1404564 spoke to Stacey. FC"]
["John W Romeo, MD","1447661764","47-5554737","TX","","Medicare","Participating","Enrollment Complete","2024-11-18","7B4567","519061","2024-12-10","Received welcome letter. mS"]
["John W Romeo, MD","1447661764","47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-11-18","Q00923012","DW7662","2025-01-06","Provider is enrolled. MS"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-10-01","Q00922944","DW7662","2025-01-06","Provider is enrolled. MS"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2024-10-01","","","2025-06-11","Received confirmation that application was approved from TMHP website. Approved on 04/10/25. \nRequest # 20657803\n6/11/25 VA"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff.  11/01/2024. PA."]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 10/07/2024. PA."]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 10/7/2024. FC"]
["Ugochukwu Ikechi Maduforo, MD","1447630033","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 10/07/2024. PA."]
["Ugochukwu Ikechi Maduforo, MD","1447630033","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","","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","","Amerigroup","Participating","Enrollment Complete","2024-10-07","","","2025-02-20","Received confirmation via roster from Mindy Wiggins, provider participating as of 10/7/2024. FC"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-02-05","Received confirmation via phone, provider participating as of 10/1/2024, call ref#1404564 spoke to Stacey. FC"]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 10/7/2024. FC"]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2025-08-06","","","2025-10-30","CAQH profile reattested - COI Updated - Information up to date - Next attestation due on 2/27/26. ML"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","1366816829","","2024-07-02","Provider is linked to Briarwood location eff 6/13/24. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-08-28","","","2024-09-19","Received email confirmation provider has been added to Network, under TIN/locations, eff. 8/28/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2017-05-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 5/1/2017. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","0452423","","2025-08-11","For Locations:6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./ 08/05/2025 MP: Called 1-800-882-4462 and spoke w Grace at Cigna. Stated provider is PAR with GRP and TIN effective 12/02/2024. PIN is 0452423. Loc on file. Call ref Grace V. 08/05/2025"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-21","1366816829","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is the NPI. Loc is not on file."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","6S2250","","2024-06-12","Received provider's welcome letter. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774238","DX4335","2024-07-01","Provider has been linked to group. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Daniel call ref#1407169, provider participating as of 8/1/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","1366816829","","2024-10-01","Approval ltrd rcvd. Effective 08/16/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","Tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/01/2024.  PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2025-08-06","For Locations:616 N Main St./6301 Andrews Hwy/6950 Eastridge Rd./08.04.2025 JB: Verification request has been emailed to SPNEAST@sedgwickcms.com, providerdata@careworks.com, Cynthia.Clancy@sedgwick.com to verify provider credentialing status."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","Tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2024-11-04","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 11/4/2024. FC"]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","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."]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2025-06-25","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Vinitha, ref # 05414545)  that provider is participating with network, effective 06/25/2025. ML"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2025-06-25","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Vinitha, ref # 05414545)  that provider is participating with network, effective 06/25/2025. ML"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Enrollment Stopped","Enrollment Complete","","","","2025-03-04","801 E Florida location is eff 6/17/2024. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Enrollment Stopped","Enrollment Complete","","","","2025-03-04","801 E Florida location is eff 6/17/2024. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Enrollment Stopped","Enrollment Complete","","","","2025-03-04","4214 Andrews location eff 6/17/2024. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","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","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-08-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 08/01/2024. PA."]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-10-15","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 10/15/2024. FC"]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-16","location is not Tricare certified and the panel is closed to new enrollments. MS"]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-12-02","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/02/2024. PA."]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-12-02","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 12/2/2024. FC"]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2024-12-02","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 12/02/2024. PA."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2024-11-04","","","2025-03-14","Received product roster from UHC,  provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2024-12-03","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 12/03/2024. PA."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2024-11-04","9502669","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-12-26","1821867714","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-12-03","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 12/03/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-11-01","Q00897593","DX4335","2024-11-27",""]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-02-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 02/03/2025. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","1821867714","","2025-08-19","For Locations: 6301 Andrews Hwy/4705 Briarwood Ave/6950 Eastridge Rd. /616 N Main St./3490 E Yukon Rd./08/15/2025 MQ: Checked Texas Mutual's directory to check provider status but provider is not found."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status update under Alliance WC payor line. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-11-04","8179156","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-11-25","","","2024-11-22","Received welcome letter. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-11-01","","","2025-06-10",""]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-11-01","","","2025-06-10",""]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Triwest VA","Enrollment Stopped","Enrollment Denied","","","","2025-02-13","Received email from Scarlett Abigail, \"Provider is set up as urgent care and is ineligible for the TriWest network.\nThanks,\nScarlett\". PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-01-06","","","2025-10-22","Per roster from Mindy sent on 10/21/25 this provider is effective 01/06/2025-SG"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2024-11-26","Enrollment complete for all 5 original location. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-11-04","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-11-04","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 11/04/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1821867714","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","0452423","","2025-08-11","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 MG: Called Cigna @ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to Penny. Per rep, provider is out of network. To be par, initiate an over the phone application. If there's more than 6 providers to be par, we can email them but we need to call them first for the ticket#. TAT 60 CD. Call ref# Penny B. 08/05/2025."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 02/03/2025. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-02-19","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/19/2025 for all locations. PIN is the NPI"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1821867714","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-17","","","2024-10-16","Received welcome letter from BCBSTX via email. Provider is participating, eff. 10/17/2024, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO. PA."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2024-11-18","","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 11/18/2024. PA"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","BCBSTX","Participating","Enrollment Complete","2024-12-20","","","2024-12-24","Received email confirming provider is par and linked to TIN/location, eff 12/20/24, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Medicare Advantage HMO, and WellMed MA HMO. PA."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Payor Follow Up","","","","2025-12-02","Emailed mhtcontractrequest@molinahealthcare.com along with W9 for enrollment process, Molina stated they did not have the original request. FC"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","","Scott&White (First Care)","Participating","Add Info Submitted","2023-12-03","","","2025-03-14","Submitted TPI to payor via delegated roster. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Received confirmation from Jessica Bess via email, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-11-04","8059727","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","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."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2024-11-04","","","2025-01-29","Received confirmation via roster, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-11-21","9443693","","2024-12-05","Received confirmation email. MS"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","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."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2024-11-04","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2024-11-04","","","2025-02-21","Received email confirming provider is par, linked to TIN/location, eff. 11/04/2024. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2024-11-04","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2025-05-05","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 5/5/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2025-05-05","","","2025-06-27","Received confirmation vial email from Mary Rodriguez, provider participating eff date 5/5/2025. FC"]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2025-02-03","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 02/03/2025. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2025-03-01","9497805","","2025-03-11","Received confirmation email of approval. MS"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","IMS","Participating","Enrollment Complete","2025-02-03","","","","Received confirmation via phone call from German Aviles, Provider participating as of 2/3/2025. FC"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-22","Per roster from Mindy sent on 10/21/25 this provider is effective 07/08/2025-SG"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2025-08-15","","","2025-08-18","Received email confirming provider's participation with network under the TIN/Location effective 8/15/25 from hpdelegation@bswhealth.org. ML"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2025-05-01","","","2025-05-07","Received validation report from SHP; provider is listed as PAR, linked to TIN/location, eff. 5/1/2025. PA"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2025-04-07","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS on 05/19/25.Effective date of 4/7/2025.  VA"]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2025-04-07","Q01054605","","2025-06-18","Provider is enrolled. MS"]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2025-04-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 04/07/2025. PA."]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2025-04-07","1314983","","2025-03-17","Received confirmation email. MS"]
["Lenita L Hinkle, APRN-NP","1477948636","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2025-04-01","5706117","","2025-04-21","Payer confirmed enrollment. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-03-03","","","2025-05-27","Received email from Keandra W. confirming  March roster has been processed. Provider now linked to TIN/locations, eff 3/3/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-03-03","","","2025-05-27","Received email from Keandra W. confirming  March roster has been processed. Provider now linked to TIN/locations, eff 3/3/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-03-03","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-04-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 04/15/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-07-02","Provider does not need to be enrolled as all claims are billed through the group under the ancillary contract. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-02-04","7K1850","","2025-03-25","Provider has been linked to to both of group's PTANS. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-11-24","Received update from Timothy at Wellmed (tgrandberry@wellmed.net) stating request to add provider is still in progress. ML"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-03-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 3/1/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-03-03","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-05-01","1407668734","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 5/1/2025 for all locations. PIN is the NPI."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Resubmitted","","","","2025-11-04","Application Resubmitted VIA website ID#808200 Case#18915623. MR"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-11-04","BCBS terminated provider eff 8/18/2025 due to no response from clinic regarding missing credentialing paperwork, PE reapplied via website. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Resubmitted","","","","2025-11-04","Application Resubmitted VIA website ID#808200 Case#18915623. MR"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-05-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-03-03","","","2025-05-16","Received notification from Mary Rodgriguez via email, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-03-03","","","2025-05-16","Received notification from Mary Rodgriguez via email, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-03-03","8217000","","2025-04-15","Receved confirmation via email from Mary Hanna, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-03-03","","","2025-04-22","Received via email from Emily Starr provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-03-14","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 03/14/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-03-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1407668734","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-05-21","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 5/21/2025 and 6/18/2025 for all locations. PIN is the NPI"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-05-21","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 5/21/2025 and 6/18/2025 for all locations. PIN is the NPI"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-03-03","","","2025-05-12","Received email confirmation from Karen Avalos provider is participating, linked to TIN/location, eff.  03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-03-03","","","2025-05-12","Received email confirmation from Karen Avalos provider is participating, linked to TIN/location, eff.  03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-03-03","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-02-04","Q01054617","","2025-06-18","Provider is enrolled. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-04-10","1407668734","","2025-08-27","Per Texas_CorCare@corvel.com, cred complete. Effective 08/26/2025. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Jeanette K Cala, MD","1629718622","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2025-08-01","8174436","","2025-07-11","Receiver welcome email. mS"]
["Jeanette K Cala, MD","1629718622","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2025-06-01","7Q1999","0008AH","2025-06-18","Received welcome letter. MS"]
["Vidya Bharati Sinha, MD","1922731322","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-17","Received notification via UHC online chat box, (spoke with Jennifer, ref #05438132) confirming provider's in-network status with Commercial, Medicare and Medicaid contracts, effective 07/08/2025. ML"]
["Vidya Bharati Sinha, MD","1922731322","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-09-01","","","2025-09-08","Per the September SHP Validation report, provider is enrolled, linked to TIN/location, eff. 9/1/2025.  ML"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2025-08-04","","","2025-09-17","Received notification via UHC online chat box, (spoke with Minette, ref #05437940) confirming provider's in-network status with Commercial, Medicare and Medicaid contracts, effective 8/4/25. ML"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2025-08-04","","","2025-12-31","Received email notification from Tonya Mongold (tmongold@pphealthplan.com) confirming August 2025 roster has been processed. Provider is linked to TIN/location, eff. 8/4/2025. ML"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","","Cigna","Participating","Enrollment Complete","2025-07-29","8306235","","2025-08-25","08/25/2025 MQ: Called 800-882-4462 and spoke w Ashley at Cigna. Stated provider is par and linked under the grp/TIN eff date 7/29/2025. PIN: 8306235. Loc is on file. Call ref# Ashley C. 8/ 25/2025"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2025-12-10","sent email to pdsdallas@aetna.com and thomass8@firsthealth.com with W-9 requesting to add provider to First Health network-SG"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-06-02","","","2025-07-10","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 6/2/25.  ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-04-15","Q01054677","","2025-06-18","Provider enrolled. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-06-02","","","2025-08-28","Received confirmation of provider enrollment effective 06/02/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-13","1285403113","","2025-06-25","Welcome ltr rcvd. Effective 06/13/2025. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-06","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/06/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/06/2025\nBlue Advantage HMO – 05/06/2025\nBlue Essentials HMO – 05/06/2025\nHealth Select – 05/06/2025\nMedicare Advantage PPO – 05/06/2025\nTriWest – 01/01/2025\nPAR – 04/19/2024. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-06","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/06/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/06/2025\nBlue Advantage HMO – 05/06/2025\nBlue Essentials HMO – 05/06/2025\nHealth Select – 05/06/2025\nMedicare Advantage PPO – 05/06/2025\nTriWest – 01/01/2025\nPAR – 04/19/2024. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1285403113","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/26/2025 for all locations. PIN is the NPI."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-13","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./5514 N Big Spring St/3490 E Yukon Rd./ 08/13/2025 MQ: Called Cigna @ 1-800-882-4462 to obtain FU status of provider and spoke with Grace. Per rep provider is par but not link under the group and TIN. To link the provider just send link letter request to intake_pdm@evernorth.com. TAT is 20-30 cal days. PIN is 0486548. Call ref# Grace V. 8/13/2025"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-13","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./5514 N Big Spring St/3490 E Yukon Rd./ 08/13/2025 MQ: Called Cigna @ 1-800-882-4462 to obtain FU status of provider and spoke with Grace. Per rep provider is par but not link under the group and TIN. To link the provider just send link letter request to intake_pdm@evernorth.com. TAT is 20-30 cal days. PIN is 0486548. Call ref# Grace V. 8/13/2025"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-07-15","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 7/15/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-07-15","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 7/15/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-12-01","1285403113","","2025-11-24","Per noreply@mdstaff.com,  – You have successfully completed the WorkWell, TX and Texas Star Network credentialing requirements.\n\nWe are pleased to let you know that you completed our credentialing requirements and that you will now be a participating member of WorkWell, TX and the Texas Star Network effective 12/01/2025. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1285403113","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 8/20/2025 for all locations. NPI# is PIN."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-06-02","","","2025-07-17","Received confirmation via email from Provider_Services_Shared.T8@90degreebenefits.com. Provider participating effective 6/2/25 ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-15","7M5460","","2025-04-25","Provider is active. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-06-02","","","2025-06-24","Received email from PPHP (pphpprovidernetwork@pphealthplan.com) confirming provider is participating, linked to TIN/location, eff. 6/2/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-06-02","","","2025-06-24","Received email from PPHP (pphpprovidernetwork@pphealthplan.com) confirming provider is participating, linked to TIN/location, eff. 6/2/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/All Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-13","1285403113","","2025-06-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-01","8980080","","2025-07-16","Received confirmation via email (roster) from Brandy Smith. Provider participating effective 7/1/25 ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1285403113","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-08","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/12/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/08/2025\nBlue Advantage HMO – 05/08/2025\nBlue Essentials HMO – 05/08/2025\nHealth Select – 05/08/2025\nMedicare Advantage PPO \nPAR – 02/21/2025\nPA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-08","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/12/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/08/2025\nBlue Advantage HMO – 05/08/2025\nBlue Essentials HMO – 05/08/2025\nHealth Select – 05/08/2025\nMedicare Advantage PPO \nPAR – 02/21/2025\nPA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-06-02","","","2025-07-10","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 6/2/25.  ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-06-02","","","2025-10-22","Per roster from Mindy sent on 10/21/25 this provider is effective 06/02/2025-SG"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-06-02","","","2025-10-22","Per roster from Mindy sent on 10/21/25 this provider is effective 06/02/2025-SG"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-06-02","","","2025-06-24","Received email from PPHP (pphpprovidernetwork@pphealthplan.com) confirming provider is participating, linked to TIN/location, eff. 6/2/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1124826490","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1124826490","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-06-02","","","2025-07-17","Received confirmation via email from Provider_Services_Shared.T8@90degreebenefits.com. Provider participating effective 6/2/25 ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","MCR enrollment was stopped, therefore RRMCR was stopped. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1124826490","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Superior","Opt Out","Opt Out","","","","2025-06-13","Provider did not select this payor. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1124826490","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1124826490","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-12","Client requested to not enroll with Medicare. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-07-15","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 7/15/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-06-02","","","2025-09-16","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-06-02","","","2025-08-28","Received confirmation of provider enrollment effective 6/2/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-06-02","","","2025-08-28","Received confirmation of provider enrollment effective 6/2/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-01","8824574","","2025-07-16","Received confirmation via email (roster) from Brandy Smith. Provider participating effective 7/1/25 ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-08-01","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-08-15","","","2025-08-18","Received email confirming provider's participation with network under the TIN/Location effective 8/15/25 from hpdelegation@bswhealth.org. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-04-07","Q01038626","","2025-05-29","Provider is linked. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1639821564","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1639821564","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-10","per email from Mindy provider eff 7/8/25-SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-07-01","3705997","","2025-08-18","Received confirmation via email from cssupport@cvty.us.com, provider partcipating as of 7/1/2025, provider id#3705997. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-07","","","2025-05-13","Provider is active eff 4/7/25. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-07","","","2025-05-13","Provider is active eff 4/7/25. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-20","","","2025-06-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-07-08","","","2025-10-29","per email from cgc.data provider effective 7/8/25-SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02",""]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd./ 5514 N Big Spring St 08/05/2025 KN: Called Cigna@1-800-882-4462 and spk w/ Jessica. Per rep, provider is INN w/ TX but not link to Grp/TIN. Rep advised that TIN 47-3465832 is contracted under Ancillary Contract and Cigna does not add individual provider to Ancillary contract so there's no need to submit app for the provider and we can just bill claim under the Name of the Grp. Rep can't provide eff date of the Grp Ancillary Contract unless service address on their file is verified. Service Address we have is not on file and per rep, we need to add it to the Grp Ancillary Profile since we need to ensure that before we bill a claim, service address is added to the In Network location list of the Grp. Per rep, submit LOI and W9 Form through email intake_pdm@evernorth.com. Subject: 2 Letter Abbreviation of State, Group Name, TAX ID# (Make sure no dash on TAX ID), Concern. TAT is 30 cal days from received date. Callref: Jessica S 08/05/25"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-07-01","","","2025-09-03","Received confirmation via phone call providefr participating eff 7/1/25 spoke to Shan call ref# 1709456. SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-07-16","","","2025-07-28","Approval ltr rcvd. Effective 07/16/2025. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-07-01","","","2025-07-02","Received email confirmation from BCBSTX that the provider is participating, effective 7/1/2025, and is linked to TIN/locations. The provider is enrolled in the following networks, all effective 7/1/2025:\nBAV – Blue Advantage HMO\nBCA – BlueChoice PPO\nHME – Health Select\nHMO – Blue Essentials\nPMC – Medicare Advantage PPO. PA"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-07-08","","","2025-10-29","per email from cgc.data provider effective 7/8/25-SG"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./5514 N Big Spring St/ 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is totally OON and not link to the tax id.To be innetwork/credentialed rep advised provider must reach out cigna to initiate the application over the phone/call.TAT 60 cal days.Call ref# Jaq A 08/05/2025."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-12-01","1245067602","","2025-11-25","Per noreply@mdstaff.com,  – You have successfully completed the WorkWell, TX and Texas Star Network credentialing requirements.\n\nWe are pleased to let you know that you completed our credentialing requirements and that you will now be a participating member of WorkWell, TX and the Texas Star Network effective 12/01/2025. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-20","1245067602","","2025-06-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-07-01","","","2025-08-20","Received confirmation via phone call from Danielle Moore, provider participating eff date 7/1/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-12","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/12/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/12/2025\nBlue Advantage HMO – 05/12/2025\nBlue Essentials HMO – 05/12/2025\nHealth Select – 05/12/2025\nMedicare Advantage PPO – 05/12/2025\nTriWest – 01/29/2025\nPAR – 09/18/2024\nPA."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025.  ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","In Process","Application Resubmitted","","","","2025-11-14","Application submitted via UHC online portal, tracking ID: MPP000004980. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Application Resubmitted","","","","2025-11-14","Application submitted via UHC online portal, tracking ID: MPP000004980. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","  1245067602","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/26/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Enrollment Stopped","Enrollment Complete","2025-04-07","7M9556, 7M9558","","2025-05-13","Provider is linked to the group. The Client has requested to stop enrollment for the provider. mS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1245067602","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1245067602","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1245067602","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1245067602","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","In Process","Application Resubmitted","","","","2025-11-14","Application submitted via UHC online portal, tracking ID: MPP000004980. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-09","CAQH profile reattested, all information up to date. Next attestation due on 4/8/26. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02","Received confirmation via email from provider_services_shared.t8@90degreebenefits.com, provider participating eff 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-10","per email from Mindy provider eff 7/8/25-SG"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","Medicare enrollment was stopped, so RRMCR was stopped as well. MS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","Medicare enrollment was stopped, so RRMCR was stopped as well. MS"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2025-08-04","","","2025-09-17","Per email from Mary, the provider is enrolled, and the effective date is 8/4/25. SG"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-10-31","","","2025-11-03","Corvel has been complete per Agie Anyanya at   Agie_Anyanya@CORVEL.com. Effective date is 10/31/2025. VA"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2025-10-15","pending medicaid. MR"]
["Sarai Avila Marks, APRN-NP","1619785656","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Sarai Avila Marks, APRN-NP","1619785656","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2025-08-15","","","2025-08-18","Received email confirming provider's participation with network under the TIN/Location effective 8/15/25 from hpdelegation@bswhealth.org. ML"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. ML"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Tejaswi Bhari Thippeswamy, MD","1811189269","","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Nina Ezinne Nwoko, APRN-NP","1689261679","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2025-10-14","","","2025-10-17","Medicaid application has been approved. 03/01/2021-10/21/2026. Request # is 20787541. VA"]
["Nina Ezinne Nwoko, APRN-NP","1689261679","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2025-10-15","","","2025-10-15","Received email notification from Chrsitelle Tchampo (hpdelegation@bswhealth.org) confirming provider's participation with network under TIN/Location, effective 10/15/25. ML"]
["Emma Aaye Zheng, APRN-NP","1861971699","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2025-10-01","6877816","","2025-10-06","Enrollment completed with effective date of 10/01/2025 ID# 6877816. MR"]
["Emma Aaye Zheng, APRN-NP","1861971699","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-10","Received email from triwest stating confirmed that TIN 75-2656723 has three contracts: 003HA87013T01, 003HC90529T01, 003HG86076T01.\nI sent a email back stating •\tWhich of the three contracts corresponds to each provider?\n•\tAre all three contracts active?\n•\tConfirmation of the effective date for each provider’s credentialing.\n•\tCopies of the welcome letters for each provider, if available. MR"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","","Medicaid","In Process","Payor Follow Up","","","","2025-12-23","Application is Pending OIG Review. VA"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2025-09-03","","","2025-10-15","per email from Mary provider effective 9/3/25-SG"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","","Cigna","Participating","Enrollment Complete","2025-10-16","4714415","","2025-10-17","Enrollment application complete with effective date of 10/16/2025 ID number 4714415. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-10-06","","","2025-11-17","per email from Addella Yarnold, provider effective date 10/6/25-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-12-15","","","2025-11-19","Spoke with Fegina on the UHC portal chat ref#05569097 and confirmed provider is participating with network & all LOBs under TIN/Location, effective 12/15/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-12-15","","","2025-11-19","Spoke with Fegina on the UHC portal chat ref#05569097 and confirmed provider is participating with network & all LOBs under TIN/Location, effective 12/15/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-10-06","","","2025-11-21","Received email notification from LaNetrice Myart (lanetrice.myart@mco.com) confirming providers participation with network under TIN/Locations, effective 10/6/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-10-06","","","2025-11-21","Received email notification from LaNetrice Myart (lanetrice.myart@mco.com) confirming providers participation with network under TIN/Locations, effective 10/6/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-10-06","","","2025-10-23","Received email notification from Tonya Mongold (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/locations, effective 10/6/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","","","2024-11-20","Received email from TRICARE Provider Inquiries <tricareproviderinquiries@triwest.com> stating provider is now credentialed with Triwest and linked to their TIN's Tax ID 47-3465832: This contract is executed with a start date of 1/1/2025\". MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-10-06","","","2025-11-19","Received email notification confirming provider's participation with network under TIN/Location, effective 10/6/25. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2025-08-15","2764085","","2025-09-17","Received email from intakepdm@evernorth.com stating application was completed and approved with effective date of 08/15/2025 ID#2764085. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-14","","","2025-11-21","Alliance WC has been approved effective 11/14/2025 per Barry Harris at barry.harris@pswca.org VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-14","","","2025-11-21","Alliance WC has been approved effective 11/14/2025 per Barry Harris at barry.harris@pswca.org VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","","","","2025-09-08","BCBS application completed with effective date of 09/09/2025. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-10-06","","","2025-12-01","Per email from Emily Starr, provider effective 10/06/2025-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-10-06","","","2025-12-01","Per email from Emily Starr, provider effective 10/06/2025-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-11-01","","","2025-11-14","per Cris with Aetna, provider effective 11/1/25, reference# 2855976246 -SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-10-06","","","2025-11-14","per email from Mary Rodriguez, provider effective 10/6/25-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Application has been approved effective GM-DATX-Texas CorCare Texas_CorCare@corvel.com VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-09-10","","","2025-09-16","Medicare application approved on 09/10/2025. Reference # is 3252390383. VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-12-15","","","2025-11-19",""]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-12-01","","","2025-12-02","Texas Mutual has been approved effective 12/01/2025. VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Participating","Enrollment Complete","","","","2025-10-10","Received email from Scarlett with TRICARE directory link @ https://triwest.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerCode=TRIWEST_I&brandCode=TRIWEST?category=&editCategorySearch=false\n\n searched provider and provider pulled up which means provider is effective. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Participating","Enrollment Complete","","","","2025-10-10","Received email from Scarlett with TRICARE directory link @ https://triwest.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerCode=TRIWEST_I&brandCode=TRIWEST?category=&editCategorySearch=false\n\n searched provider and provider pulled up which means provider is effective. MR"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Tella, provider effective 10/1/25, reference# 21764932-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Tella, provider effective 10/1/25, reference# 21764932-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Addia with First Health, provider effective 10/1/25, reference# 1814893-SG"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Addia with First Health, provider effective 10/1/25, reference# 1814893-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-10-06","","","2025-12-05","Received email notification from Erica Lee (elee22@humana.com) confirming provider's participation with network under TIN/Location, effective 10/6/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-10-06","","","2025-11-14","per email from Mary Rodriguez, provider effective 10/6/25-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-12-15","","","2025-11-19","Spoke with Fegina on the UHC portal chat ref#05569097 and confirmed provider is participating with network & all LOBs under TIN/Location, effective 12/15/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-10-06","","","2025-12-04","Per Mindy in 12/4/25 meeting, provider effective 10/6/25-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-12-15","","","2025-11-19","Spoke with Fegina on the UHC portal chat ref#05569097 and confirmed provider is participating with network & all LOBs under TIN/Location, effective 12/15/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Payor Follow Up","2025-10-06","","","2025-11-14","Requested enrollment status via email, sent to payor. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-09-24","","","2025-10-03","Received email from BCBS stating provider enrollment application was complete effective date of 09/24/2025. MR"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Addia with First Health, provider effective 10/1/25, reference# 1814893-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in Process. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in Process. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-10-06","","","2025-11-21","Received email notification from LaNetrice Myart (lanetrice.myart@mco.com) confirming providers participation with network under TIN/Locations, effective 10/6/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-14","","","2025-11-21","Alliance WC has been approved effective 11/14/2025 per Barry Harris at barry.harris@pswca.org VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2025-11-21","Received email from Tran, Monique <Monique.Tran@cignahealthcare.com> stating \"They need:\nCompleted Credentialing Application\nMultiple Location Spreadsheet\nFor each location, Cigna requires:\nFacility License\nFacility Accreditation or Medicare Certification Sent email to Moises Leiva Davis (mleiva@westexurgentcare.com) requesting the required documents they listed. MR"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-10-06","","","2025-11-17","per email from Addella Yarnold, provider effective date 10/6/25-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-09-23","","","2025-09-23","Medicare application has been approved. Tracking # is   VA."]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-11-15","","","2025-10-17","Received email notification from Christelle Tchampo (hpdelegation@bsw.org) confirming provider's participation with network under location/TIN, effective 11/15/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-11-15","","","2025-10-17","Received email notification from Christelle Tchampo (hpdelegation@bsw.org) confirming provider's participation with network under location/TIN, effective 11/15/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-10-01","","","2025-11-14","per Tella, provider effective 10/1/25, reference# 21764932-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-10-06","","","2025-10-23","Received email notification from Tonya Mongold (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/locations, effective 10/6/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-10-06","","","2025-10-23","Received email notification from Tonya Mongold (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/locations, effective 10/6/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-10-06","","","2025-10-23","Received email notification from Tonya Mongold (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/locations, effective 10/6/25. ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-08-01","","","2025-10-02","Railroad Medicare has been approved. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-08-01","","","2025-10-02","Railroad Medicare has been approved. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-11-26"," Application is still in review. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-10-06","","","2025-12-01","Per email from Emily Starr, provider effective 10/06/2025-SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","","","2025-11-21","Received email from TRICARE Provider Inquiries <tricareproviderinquiries@triwest.com> stating provider is now credentialed with Triwest and linked to their TIN's Tax ID 47-3465832: This contract is executed with a start date of 1/1/2025\". MR"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-11-01","","","2025-11-14","per Cris with Aetna, provider effective 11/1/25, reference# 2855976246 -SG"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-11-01","","","2025-11-14","per Cris with Aetna, provider effective 11/1/25, reference# 2855976246 -SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","per email from Addella, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","per email from Addella, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-09-01","","","2025-10-10","Railroad Medicare has been approved effective 09/01/2025. Reference # 25280000475. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via email, sent to payor. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","per email from Addella, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-12-01","","","2025-12-22","per email from Brandy, provider effective 12/1/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-11-03","","","2025-12-19","per roster sent by Mindy, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Pending Other Enrollment","Payor Follow Up","","","","2025-11-21","Received email from Tran, Monique <Monique.Tran@cignahealthcare.com> stating \"They need:\nCompleted Credentialing Application\nMultiple Location Spreadsheet\nFor each location, Cigna requires:\nFacility License\nFacility Accreditation or Medicare Certification Sent email to Moises Leiva Davis (mleiva@westexurgentcare.com) requesting the required documents they listed. MR"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-11-26"," Application is still in review. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-11-03","","","2025-12-22","Per firsthealth website, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-11-03","","","2025-12-31","Per email from cgc.data, provider effective 11/3/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress. MR"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-11-14","","","2025-12-15","Received email notification from Jackie Hipolito (providerinfo@usamco.com) confirming provider's participation with network under TIN/Location, effective 11/14/25. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-01-08","","","2025-11-04","Corvel Application has been approved effective 1/8/2024."]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-01-08","","","2025-11-04","Corvel Application has been approved effective 1/8/2024."]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","","","2025-11-21","Received email from TRICARE Provider Inquiries <tricareproviderinquiries@triwest.com> stating provider is now credentialed with Triwest and linked to their TIN's Tax ID 47-3465832: This contract is executed with a start date of 1/1/2025\". MR"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2025-11-14","Application submitted via delegated roster 11/14/25-SG"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","Received email notification from Karen Avalos (kavalos@ghn-mci.com) confirming provider's participation under location/TIN, effective 11/3/25. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-09-01","","","2025-10-06","Medicare application has been approved on 10/02/2025. Reference # 3252620822. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-09-01","","","2025-10-06","Medicare application has been approved on 10/02/2025. Reference # 3252620822. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via email, sent to payor. ML"]
["Michael Anthony Gonzales, APRN-NP","1154053940","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-14","","","2025-11-21","Alliance WC has been approved effective 11/14/2025 per Barry Harris at barry.harris@pswca.org VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Application has been approved effective GM-DATX-Texas CorCare Texas_CorCare@corvel.com VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","2025-12-15","","","2025-11-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Wellcare","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-07","","","2025-11-13","Application has been approved for Alliance WC per Barry Harris at Barry Harris barry.harris@pswca.org. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Superior","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-12-15","","","2025-10-27","Medicare application has been approved effective 12/15/2025. PTAN is 7Y3177 and the reference # is 3252860739. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-12-15","","","2025-10-27","Medicare application has been approved effective 12/15/2025. PTAN is 7Y3177 and the reference # is 3252860739. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-12-15","","","2025-10-31","Railroad Medicare has been approved effective 12/15/2025. Reference # 25300000980. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress. MR"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via email, sent to payor. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via email, sent to payor. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-12-10","Application is in credentialing process. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","per email from Addella, provider effective 11/3/25-SG"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-11-14","","","2025-12-15","Received email notification from Jackie Hipolito (providerinfo@usamco.com) confirming provider's participation with network under TIN/Location, effective 11/14/25. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2025-11-14","Application submitted via delegated roster 11/14/25-SG"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-08-25","","","2025-10-16","Medicare application has been  approved effective 8/25/2025. Ref # 3252661008 VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","","","2025-10-27","Railroad Medicare has been approved effective 10/27/2025. Reference # 25294001826 VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","","","2025-10-27","Railroad Medicare has been approved effective 10/27/2025. Reference # 25294001826 VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2025-11-24","Received email from Tran, Monique <Monique.Tran@cignahealthcare.com> stating \"They need:\nCompleted Credentialing Application\nMultiple Location Spreadsheet\nFor each location, Cigna requires:\nFacility License\nFacility Accreditation or Medicare Certification Sent email to Moises Leiva Davis (mleiva@westexurgentcare.com) requesting the required documents they listed. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-07","","","2025-11-13","Application has been approved for Alliance WC per Barry Harris at Barry Harris barry.harris@pswca.org. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-11-03","","","2025-12-19","per roster sent by Mindy, provider effective 11/3/25-SG"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","per email from Addella, provider effective 11/3/25-SG"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Application has been approved effective GM-DATX-Texas CorCare Texas_CorCare@corvel.com VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Application has been approved effective GM-DATX-Texas CorCare Texas_CorCare@corvel.com VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2025-12-15","Requested enrollment status via online chat, spoke with Kathrin R. and confirmed application is still in process. Reference #: 05617281. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","In Process","No Value Specified","","","","",""]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","In Process","No Value Specified","","","","",""]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-11-03","","","2025-12-17","Received email notification from Karen Avalos (kavalos@ghn-mci.com) confirming provider's participation under location/TIN, effective 11/3/25. ML"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress. MR"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-11-03","","","2025-12-22","Per firsthealth website, provider effective 11/3/25-SG"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-12-01","","","2025-12-22","per email from Brandy, provider effective 12/1/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-12-01","","","2025-12-02","Texas Mutual Has been approved effective 12/01/2025. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-12-12","Spoke with a Cigna HealthSpring representative who stated I am not able to speak with a supervisor and was instructed to email txmacontracting@cignahealthcare.com\n. I advised the representative that I have been emailing for months with no response. She stated that this is the process and the only action I can take at this time. MR"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-11-07","","","2025-11-13","Application has been approved for Alliance WC per Barry Harris at Barry Harris barry.harris@pswca.org. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-23","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-23","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Application Submitted","2025-10-13","","","2025-10-02","Broadspire Roster submitted to updates@primehealthservices.com VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-10-13","","","2025-11-12","Broadspire has been approved. They backdated it for 10/13/2025. They do not send approval letters. updates@primehealthservices.com. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Pending Other Enrollment","Payor Follow Up","","","","2025-11-21","Received email from Tran, Monique <Monique.Tran@cignahealthcare.com> stating \"They need:\nCompleted Credentialing Application\nMultiple Location Spreadsheet\nFor each location, Cigna requires:\nFacility License\nFacility Accreditation or Medicare Certification Sent email to Moises Leiva Davis (mleiva@westexurgentcare.com) requesting the required documents they listed. MR"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Pending Other Enrollment","Payor Follow Up","","","","2025-11-21","Received email from Tran, Monique <Monique.Tran@cignahealthcare.com> stating \"They need:\nCompleted Credentialing Application\nMultiple Location Spreadsheet\nFor each location, Cigna requires:\nFacility License\nFacility Accreditation or Medicare Certification Sent email to Moises Leiva Davis (mleiva@westexurgentcare.com) requesting the required documents they listed. MR"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-12-10","Application in progress. MR"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-11-25","Sent email needing a update. MR"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2025-12-10","Application is in credentialing process. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-09-29","","","2025-10-31","Railroad Medicare has been approved effective 9/29/2025. Reference # 25295001337. VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-09-29","","","2025-10-22","Medicare application has been approved. PTAN # is 7Y0524, effective 09/29/2025. Reference # 3252790585 VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Wellmed","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted roster via UHC roster upload portal, tracking ID: MPP000005823. ML"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","USA PPO","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Aetna","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Humana","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","In Process","Application Submitted","","","","2025-12-15","Submitted application via delegated roster 12/15/25-SG"]
["Austin Lee Hall, NP","1194601237","83-0358685","TX","Midland Community Healthcare Services","PPHP","In Process","Application Submitted","2025-12-15","","","2025-12-15","Submitted application via delegated roster submission.  ML"]
["Legesse Fulla Tebeje, MD","1124074513","47-5554737","TX","Midland Inpatient Medical Associates","Rail Road Medicare","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Railroad has been approved. effective 12/12/2025. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Application Submitted","","","","2025-12-15","Application has been submitted. Tracking # 121520250004629 VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2025-12-15","Submitted application online @ pswca.org and sent documents to contracts@pswca.org. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-16","","","2025-12-19","Application has been approved effective 12/16/2025 from www.corvel.com VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-16","","","2025-12-19","Application has been approved effective 12/16/2025 from www.corvel.com VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-22","Sent application to Tricia for signature. Waiting for it so that I can send it back to Sedgwick. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-12-22","Sent application to Tricia for signature. Waiting for it so that I can send it back to Sedgwick. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-12-12","","","2025-12-12","CAQH profile reattested. All information up to date. Next attestation due on 4/11/26. ML"]
["Jonathan R Morales, FNP","1396350070","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-12-22","Submitted information to wwtxcontracts@texasmutual.com . Waiting for his individual link to finish the application. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-12-22","Submitted information to wwtxcontracts@texasmutual.com . Waiting for his individual link to finish the application. VA"]
["Jonathan R Morales, FNP","1396350070","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2025-12-17","Submitted application VIA website Case # 19127796. MR"]
["James Harold Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Liberty Mutual","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James Harold Barnett, MD","1356484497","27-4061759","TX","","Superior","Participating","Enrollment Complete","2019-10-01","1356484497","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["James Harold Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-08-19","12124562","","2025-11-17","CAQH profile reattested. All information up to date, next attestation due on 3/17/26. ML"]
["James Harold Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2020-01-01","1356484497","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["James Harold Barnett, MD","1356484497","27-4061759","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["James Harold Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","1998-07-23","1356484497","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 7/23/1998. – Jerha Gayorgor"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","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","Pankaj N. Patel, MD PA","Boon Chapman","Participating","Enrollment Complete","2000-07-01","1124009766","","2020-09-30","Enrollment through PHCS"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","Medicare","Participating","Enrollment Complete","2008-02-19","00636G","","2020-07-28","7/28/2020 - Rec'd a lettter from Medicare to confirm this provider PAR status - 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","","TriCare Standard","Participating","Enrollment Complete","2024-01-02","","","2024-01-09","Confirmed provider is linked to Ste. 271 via the self service portal. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","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","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"]
["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","","Omni PPO","Participating","Re-Credentialing","2021-12-06","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Boon Chapman","Participating","Re-Credentialing","2021-12-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed. eff 1/2/2024. MS"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-26"," Received confirmation from payor via email stating roster is complete; provider is PAR and  linked to the TIN/location, effective 07/14/2024. PA."]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Alliance WC","Participating","Enrollment Complete","2025-11-07","","","2025-11-13","Application has been approved for Alliance WC per Barry Harris at Barry Harris barry.harris@pswca.org. VA"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-07-05","","","2024-07-29","Received email confirmation provider is PAR and linked to TIN/location, eff. 07/05/2024. PA."]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1528000734","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","2015-06-09","","","2020-10-05","Enrolled thru Multiplan"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","","Aetna","Participating","Enrollment Complete","2018-10-19","5113559","","2020-03-25","3/25/2020--S/W Ella of Aetna 8003531232, provider NPI# is on file for the provider and is participating effective 10/19/2018 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref#: 5194745657. \ntisha rader"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1659366433","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider is :  \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Willie Watson-Effective 04/15/2017\" - Stacey Hudak"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2017-04-15","1659366433","","2020-10-05","enrolled thru PHCS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2021-08-01","1103233","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","","Amerigroup","Participating","Add Info Submitted","2021-08-01","12731150","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1518951342","","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","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-26","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","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","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff. 3/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2021-01-07","","","2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 01/07/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1518951342","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-02",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","1518951342","","2023-12-18","Welcome letter rcvd. Provider eff 12/01/2023. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","","First Health Coventry","Participating","Application Resubmitted","2021-08-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","IMS","Participating","Enrollment Complete","2021-01-07","","","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-08-15","1518951342","","2025-08-19","For Locations: 6301 Andrews Hwy/4705 Briarwood Ave/6950 Eastridge Rd. / 08/15/2025 MQ: Checked Texas Mutual's directory to check provider status but provider is not found."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2025-07-31","","","2025-07-31","07/31/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024- Spoke to Zach B call ref#2192834359 616 N Main St location eff as of 02/1/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","TriCare Standard","Participating","Enrollment Complete","2021-06-30","","","2021-07-29","7/29/2021 Upon review of the Self-Service portal, confirmed provider is certified under the group Tax ID effective 6/30/2021. KFrazier"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","1518951342","","2023-12-18","See Alliance WC payor line for details. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-08-11","","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Debbie P Reese, MD","1629074984","75-2133441","TX","Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","10120298","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","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"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2025-08-06","","","2025-11-17","CAQH Profile updated/ All information up to date. Next attestation due on 3/17/26. ML"]
["Debbie P Reese, MD","1629074984","75-2133441","TX","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","Debbie P. Reese, MD PA","Amerigroup","Participating","Enrollment Complete","2023-12-11","","","2024-02-01","2/1/2024 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 12/11/2023.  DCannon"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-03-20","1942216122","","2020-08-19","08/19/2020 - Rec'd spreadsheet confirmation from the payer stating this provider is linked to the PRIMED DELEGATED CONTRACT with this TIN/Service Location and networked with the following: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","1942216122","","2025-09-09","09/09/2025 AC: Per email response received on 04/08/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/11/2024 all locations. PIN is NPI."]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1902426","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008 PID # 1902426\ntisha rader"]
["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","Permian Gastroenterology 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"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","CAQH","Participating","CAQH Reattested","2025-08-06","10594793","","2025-08-06","08/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Amerigroup","Participating","Enrollment Complete","2013-03-23","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","Permian Gastroenterology PA","Aetna","Participating","Enrollment Complete","2005-11-15","546640","","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 Cannon Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","2019864","2559513","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. KFrazier"]
["John Cannon Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-18","1013923291","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John Cannon Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","119245205","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Srikanth R Deme, MD","1124103338","75-2949900","TX","Srikanth Deme MD PA","CAQH","Participating","CAQH Reattested","2025-08-05","","","2025-11-17","CAQH profile updated and all information up to date. Next attestation due on 3/17/25. ML"]
["Srikanth R Deme, MD","1124103338","75-2949900","TX","Srikanth Deme MD PA","United Health Care","Participating","Enrollment Complete","2023-09-19","001806789","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 9/19/2023.  MPIN# 001806789.  DCannon"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1811900657","","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"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","Medicare","Participating","Action Needed","2007-11-01","8F6462","00Y323","2025-09-24","The Revalidation for his practice is on hold because I am needing banking information.  I reached out on 9/17/2025 and 9/24/25. VA"]
["Bhuvana Balasekaran, MD","1770564080","46-1602172","TX","Bhuvana Balasekaran, MD PA","TriWest HC Alliance","Active","Payor Follow Up","2020-03-20","1770564080","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","Amerigroup","Participating","Enrollment Complete","2012-03-01","10016928","","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"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760485502","","2020-07-01","07/01/2020 - Rec'd confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1295724698","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1295724698","","2020-07-15","7/15/2020 - Received email spreadshee from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Kirit N Patel, MD","1295724698","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2017-11-01","1295724698","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2012-03-01","01350302","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-06","12019639","","2025-11-20","CAQH profile reattested, all information up to date. Next attestation due on 3/20/25 ML"]
["Dario Beltran, MD","1912100850","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2009-12-01","8L21655","0008AH","2021-11-15","11/15/2021 Per PECOS provider is PAR and linked to group PTAN/location.  PTAN 8L21655 effective 12/1/2009.  DCannon."]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","1912991084","","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","1912991084","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 02/19/2016.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","1912991084","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2017 for all locations. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff 10/4/2024\n6301 Andrews Hwy eff 5/6/2024\n6950 Eastridge Ave & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1912991084","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. loc is on file. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","1912991084","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2017-09-01","1912991084","","2025-08-28","\n08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2017 for all locations. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2020-04-15","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 04/15/2020. PA."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1912991084","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1912991084","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-01-01","","","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","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024.."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024.."]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","","","2023-08-22","Confirmed provider is active at this location. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","1912991084","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2015-07-28","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/28/2015.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637766","","2023-05-02","5/2/2023 Per confirm par status note -   Per rep, provider is participating with an effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637766. As per Donna from there Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing Date is available. Service location is on file. Call ref#:610340.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-09-12","3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2022-09-12","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2022-09-12","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1578557468","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","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","Vincent P. Rascon","Humana","Participating","Enrollment Complete","2011-01-01","1346236924","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","Vincent P. Rascon","Medicare","Participating","Enrollment Complete","1998-06-01","00147E","N/A - no group enrollment/PTAN","2020-03-10","03/10/2020 - Logged onto provider account through PECOS and found that this provider only has an individual enrollment. Is not reassigned to group - Stacey Hudak"]
["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","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1730181389","","2020-10-02","10/02/2020 - rec'd email from the payer confirming this provider has been added to the primed delegation - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1730181389","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/01/2024 for all locations. PIN is the NPI."]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Provider effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23"," 09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22- TIN is active and has direct contract, provider in network due to association with TIN"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-14","","","2021-08-26","8/26/2021 Rcvd roster from Scott & White/First Care, provider is listed as PAR under group TIN/location effective 7/14/2020.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC Part A Only","","2020-09-01","09/01/2020 - RHC - Part A Only. Provider cannot be enrolled under the group, as this would be billed under the facility - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Liberty Mutual","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","United Health Care","Participating","Enrollment Complete","2017-10-31","1316965403","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","USA PPO","Participating","Enrollment Complete","2002-11-15","1316965403","562697415","2020-08-21","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-10-26","","","2024-10-07","Received confirmation via email, provider participating as of 10/26/2024. FC"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-08-23","","","2025-03-04","Confirmed enrollment via portal. MS"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","Humana","Participating","Enrollment Complete","2018-08-31","","","2021-03-09","3/9/2021 Per \"Comform Par Status\" notes the provider is participating under the group and TIN# effective 8/31/2018, physical location is on file.  DCannon"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Cigna","Participating","Enrollment Complete","2014-10-08","1093821274","","2020-08-26","08/26/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Liberty Mutual","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","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","81-3411343","TX","Permian Basin Kidney Center Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1780892760","","2020-10-05","Enrollment through PHCS"]
["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","26-3789190","TX","Permian Physician Services","Multiplan","Participating","Enrollment Complete","2024-09-13","","","2024-11-08","Received confirmation via email from Jessica Bess, provider participating as of 9/13/2024. FC"]
["Anand C Reddy, MD","1780892760","81-3411343","tx","Permian Basin Kidney Center Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1780892760","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1780892760","","2025-04-07","Per the rep, Humana sent reassignments and the provider has been loaded in the Tricare Prime Health Plan Network via the online directory. MS"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1780892760","","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"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2024-06-20","","","2025-01-06","Provider is enrolled. MS"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02274773","DZ2789","2020-06-11","06/11/2020 - Found EFF info through payer site - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","Superior","Participating","Enrollment Complete","2020-10-01","1780892760","","2020-10-01","10/01/2020 - rec'd email from the payer stating this provider has been updated and made EFF off the roster - Stacey Hudak"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2024-10-01","1942454525","","2024-11-20","Provider is loaded to this location per the directory. MS"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-08-05","","","2024-10-29","Received notification via email, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-08-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 08/05/2024.  PA"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1942454525","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-03","Received confirmation via phone call from German Aviles, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2024-10-01","0323199","","2024-10-18","Received confirmation email. MS"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Medicaid","Participating","Add Info Submitted","2024-10-01","","","2025-12-17","Submitted address changes. Request # 20853522 VA"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email from Jessica Bess, provider participating with Medicaid product effective 8/5/2024. FC"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Add Info Submitted","2020-09-01","1093928913","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2012-12-01","","","2020-09-14",""]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/12/2020.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","","2021-04-22","4/22/2021 Rcvd email from Kim Brechbiel <KJBrechbiel@aetna.com> that provider is particpating and linked to TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","","HealthSmart PPO","Participating","Add Info Submitted","2012-10-29","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","","IMS","Participating","Add Info Submitted","2020-08-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2017-08-01","460057ZGML","TXB115966","2023-05-10","5/10/2023 Per PECOS provider is PAR and linked to group effective 8/1/2017.  PTAN # 460057ZGML.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Multiplan","Participating","Add Info Submitted","2023-05-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2013-09-01","1336304120","","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","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","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2013-08-29","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/29/2013.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-09-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1336304120","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2016-01-11","1336304120","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked under: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Maung Kyaw Min Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Maung Kyaw Min Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1306167309","","2020-07-27","IMS complete"]
["Maung Kyaw Min Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1306167309","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Maung Kyaw Min Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Payor Follow Up","2020-04-15","1306167309","","2025-06-04","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Medicare","Participating","Enrollment Complete","2023-07-31","6J9810","","2024-02-16","Received approval letter eff 7/31/2023. MS"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Cigna","Participating","Enrollment Complete","2023-09-19","","","2025-08-11","08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id .Provider id# 5302942.Physical location is onfile.Call ref# Jaq A 08/05/2025."]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","Leo Villaroman, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-09","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Tricare Prime","Participating","Enrollment Complete","2023-06-02","","","2024-01-25","Confirmed via the Tricare portal, the provider is Credentialed and In Network. MS"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","Amerigroup","Participating","Enrollment Complete","2023-09-08","1306162557","","2024-10-02","Received confirmation via roster from Cassandra, provider participating with CAID, Starkids, Plus, Chip, Peri, DualCaid, DualCare as of 9/8/2023, Mltpcaid, MltpPlus as of 5/30/2023,MltpStarKids as of 5/24/2022. FC"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2014-07-28","P01476166","DS1746","2020-05-14","05/14/2020 - Rec'd proof of medicare enrollment and was able to confirm EFF RR through payer site - Stacey Hudak"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","IMS","Participating","Add Info Submitted","2018-10-15","1306162557","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this is also participating - Stacey Hudak"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Asif Ali Khan 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 Ali Khan Ansari, MD","1528299872","26-3789190","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-02-28","Received email from BSW HP Region,  confirming provider is linked to TIN/location combination, eff. 11/01/2024. PA. Provider participating in BSWH  Employee Network Tier 1, Medicare Advantage, BSW Premier HMO, BSW Premier PPO. PA."]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2024-09-13","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 9/13/2024. FC"]
["Asif Ali Khan 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 Ali Khan Ansari, MD","1528299872","81-3411343","TX","Permian Basin Kidney Center Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-04-03","","","2022-03-30","3/30/2022 Per email from S & W delegated roster provider load from December has been completed and provider is PAR effective 4/3/2020.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","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 Ali Khan Ansari, MD","1528299872","81-3411343","tx","","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","Permian Basin Kidney Center Inc","TriCare Standard","Participating","Enrollment Complete","2019-08-28","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 Ali Khan Ansari, MD","1528299872","81-3411343","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02323200","DZ2789","2020-05-04","05/04/2020 - verified through portal and moved to completed status - Stacey Hudak"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","tx","Permian Basin Kidney Center Inc","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Audrey N Mangwiro, MD","1346265162","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-04-01","4/1/2021 Rcvd confirmation email from payor that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-11-11","7F1250","","2025-01-21","Provider is active. MS"]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-12-02","","","2025-08-12","\"08.06.2025 KF: Called First Health Coventry @ 800-226-5116 and spoke with Crystal. Provider is in network and link to TIN effective 12/02/2024. Location is on file. PIN is 2714285. Call ref# 1670982\n\""]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","","","","2025-04-23","Providers speciality has been updated to Critical Care (Intensivists) MS"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2021 Provider is listed on the HealthSmart website provider directory as participating at location.  I have requested an updated delegated roster from cgc.data@healthsmart.com.  DCannon"]
["Nancy Ny Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-02-21","Received email from Network Relations-Humana, confirming provider is par, linked to TIN/location, eff.  10/07/2024. PA."]
["Nancy Ny Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/7/2024. PA."]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-01-11","","","2020-10-23","10/23/2020 Provider is participating with TriCare Prime; therefore, remains certified as a non-network effective 1/11/2018. Kimberly Frazier"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1295109510","","2020-07-17","7/17/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2016-05-10","1295109510","752656723","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-04-06","1295109510","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd emailed spreadsheet showing this provider is EFF with these networks: Multiplan/PHCS/BeechStreet but under the delegation with: West Texas Physicians Alliance - Stacey Hudak"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-08-06","12803191","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1215254156","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","First Health Coventry","Participating","Application Resubmitted","2023-05-30","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2022-11-16","1366728909","","2023-12-15","12/15/2023 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 11/16/2022.  TPI # 1366728909.  DCannon"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2015-10-01","2785559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2015-11-19","1770883191","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","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.\""]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","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","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1275044422","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","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"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","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","Premier Family Care, Inc","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"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1275044422","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","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","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","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-06-22","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","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","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"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1013990761","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-04-03","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2021-04-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2021-04-13","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Application Resubmitted","2017-05-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","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"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-08-31","08/31/2020 - moved to completed status afer reviewing follow up complete note - under PRIMED - Stacey Hudak"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1437175163","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-11-14","","","2024-01-26","Confirmed Provider is credentialed  and in network with Tricare. MS"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","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"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","United Health Care","Participating","Enrollment Complete","2015-12-14","2748091","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","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","Premila Johnson, MD, LP","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/20/2020.  DCannon"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","","Multiplan","Participating","Enrollment Complete","2014-06-04","1184727562","West Texas Physicians Alliance","2020-07-06","07/06/2020 - Rec'd email from the payer stating: \n\"Thank you for contacting our Service Department at Multiplan and Beech Street. Here is the following information we have on file for Johnson, Premila:\n\nNetwork:  MPI\nNetwork Participation effective: 09/01/2012 Contract Source Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech Street\nNetwork Participation effective: 06/04/2014 Contract Source Group contract through: West Texas Physicians Alliance\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","Premila Johnson, MD, LP","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","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"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-06-02","002854139","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 06/02/2020. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-12-03","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 12/03/2024. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-08-01","","","2025-08-13","For locations: 6950 Eastridge Rd./ 6301 Andrews Hwy 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id effective 08/01/2023.Provider id# 9560591.Physical location is onfile.Call ref# Jaq A 08/05/2025."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1437356730","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/11/2024 all locations. PIN is NPI."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1437356730","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","1437356730","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 12/20/2023 for all locations. NPI# is PIN."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","","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","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","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","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","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","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-09-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 9/1/2024. FC"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-29","location is not Tricare credentialed and they are not taking new application. MS"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete","2024-04-29","","","2024-07-02","Provider is linked to this location 4/29/24. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 12/1/2018.  DCannon"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-03-01","","","2024-07-04","7/4/2024 provider participating as of 3/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-01","1437356730","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-09-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","12235261","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Allen E Gibson, MD","1912068446","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","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","Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2020-11-01","1901814","","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","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"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1760501720","","2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","1760501720","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-25",""]
["Gerardo Mendoza Catalasan, MD","1760501720","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.\""]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1901802","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo Mendoza Catalasan, MD","1760501720","75-2656723","TX","","Medicaid","Participating","Add Info Submitted","2023-08-21","1760501720","","2025-12-17","Submitted address changes. Request # 20854092 VA"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2020-05-13","8867748","","2020-05-14","05/14/2020 - Rec'd email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/13/2020. Your provider identification number is 8867748. \" - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","9469407","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 10/1/2019.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 07/1/2024. PIN 8867748. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Humana","Participating","Enrollment Complete","2020-03-20","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 03/20/2020. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1376723361","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","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","","Scott&White (First Care)","Participating","Enrollment Complete","2024-12-03","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 12/03/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-03","13780299","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","13780299","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1376723361","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1376723361","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1376723361","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-01","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/location, eff. 09/01/2022. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2025-12-10","Pending group enrollment. Emailed  TXMAContracting@cignahealthcare.com for status of contract request. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","1376723361","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","1376723361","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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","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","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-09-08","","","2025-05-29","Received confirmation via roster from Mindy Wiggins, provider participating as of 3/3/2025 with Medicare products. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","9469407","","2023-10-19","10.16.2023 S/W Chris of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective on 06/19/2023. No next recredentialing date available. PIN: 9469407. Servicing location is on file. Payer# 60054. Call ref# 6166862305. - Willie Ravas"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","USA PPO","Participating","Enrollment Complete","2018-02-04","","","2023-11-20","11/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 2/4/2018.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-08-22","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 08/22/2020. PA"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-09-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 9/1/2024. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","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","","Medicare","Participating","Enrollment Complete","2024-11-10","","","2025-02-20","Provider is linked to PTAN 6P6053. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Ambetter","Participating","Confirm Par Status","2022-05-01","","","2025-02-20","Received confirmation from Cynthia F. provider is par, linked to TIN/location, eff. 5/1/2022. PA."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-03-01","1376723361","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2018 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-03-01","1376723361","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2018 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-01-03","","","","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Sedgwick","Participating","Enrollment Complete","","1376723361","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 2/21/2024 for all locations. NPI# is PIN."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN. PIN 8867748. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 5/1/2023. PIN 8867748. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1376723361","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1376723361","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1376723361","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2007-11-01","P00710890","DO2096","2020-08-28","08/28/2020 - moved to completed status after confirming EFF info through payer site - Stacey Hudak"]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-03-16","1447415476","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Re-Credentialing","2019-09-01","1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Wayne L Sager, MD","1225182314","75-2133441","TX","Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1225182314","","2020-08-27","08/27/2020 -Rec'd email from the payer stating \"\nThank 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: - Wayne Sager-Effective 04/15/2017\" - Stacey Hudak"]
["Wayne L Sager, MD","1225182314","75-2133441","TX","Midland Pediatric Associates, PLLC","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1194813709","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","CAQH","Participating","CAQH Reattested","2025-07-31","12064910","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-01-01","","","2025-08-04","TMHP was approved for Revalidation. Request # 20390244.  8/4/2025. VA"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2023-12-04","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-01-01","6E9314","","2023-12-12","Provider is enrolled eff 1/1/2024. MS"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2011-09-10","1376556019","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-10-2011 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1376556019","","2020-07-14","07/14/2020 - Rec'd email back from the delegated team stating this provider has been linked to this TIN since 1-1-2017 **see the other Enrollment Complete line for details about specific products and when they became EFF** - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-05-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/5/2016.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-08-01","1376556019","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1376556019","","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"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","187586602","079837301","2024-07-26","Approval ltr rcvd for 2402 W Wall St. Effective 05/29/2023. Jen Videan"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","1558392779","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Rebecca Annette Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1174241","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rebecca Annette Sanchez, PA","1174846364","46-3131679","TX","","Scott&White (First Care)","Participating","Add Info Submitted","2020-09-28","","","2025-03-18","Submitted TPI to payor via delegated roster. PA."]
["Rebecca Annette Sanchez, PA","1174846364","46-3131679","TX","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 Annette Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-11-18","1174846364","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["Rebecca Annette Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1174846364","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","Ayodele O Olowookere MD, PA","Medicaid","Participating","Enrollment Complete","2014-05-05","21465602","337067801","2020-06-30","06/30/2020 - Rec'd copy of approved Medicaid letter showing EFF TPI from the clinic - Stacey Hudak"]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2006-06-01","1487837712","West Texas Physicians Alliance","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2012-02-23","1487837712","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1487837712","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-12","Received email confirmation provider is PAR, and linked to TIN/location, eff. 9/1/2024. Provider is participating in the following LOB's:  CHIP RSA, Star Health Foster Care, Chip, Star, Star Plus, Star Kids, MMP Medicaid, Chip Perinate, Exchange, Medicare, MMP Medicare, and MAPD. PA."]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2025-12-10","Application is in credentialing process. VA"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","Alliance WC","Participating","Enrollment Complete","2025-11-07","","","2025-11-13","Application has been approved for Alliance WC per Barry Harris at Barry Harris barry.harris@pswca.org. VA"]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-11-01","5226562","","2024-11-26","Received confirmation. MS"]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-03","P01787073","DW7662","2025-01-06",""]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-22","1013320050","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 5/22/2024, and is linked to the TIN and location. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","IMS","Participating","Enrollment Complete","2024-05-22","","","2024-08-27","As per Kodi Cox provider participating as of 5/22/2024 received via email. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Aetna","Participating","Enrollment Complete","2024-05-22","602568","","2024-08-22","Spoke to Jessica call ref#6200938288 provider participating as of 5/22/2024 as a SPEC. I will email Brandy Smith to have his designation role corrected to PCP. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-05-22","P13563525","","2024-09-09","Received confirmation from Aleece Moerbe via email provider participating as of 5/22/2024. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Cigna Healthspring","Enrollment Stopped","Enrollment Stopped","","","","2025-11-13","Medicare enrolled was stopped.  This is a Medicare Adv. plan and will pend the Medicare enrollment status. Jen Videan"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Cigna","Participating","Enrollment Complete","2025-02-15","9884987","","2025-01-17","Received confirmation email. MS"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","BCBSTX","Participating","Enrollment Complete","2024-09-04","","","2024-09-05","Received email confirmation provider is PAR and linked to TIN/location, eff. 9/4/2024. Provider is participating in the following LOB's: Blue Choice PPO: 09/04/2024 \nBlue Essentials HMO: 09/04/2024  \nHealth Select: 09/04/2024 . PA"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","Basin Dermatology","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","Basin Dermatology","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"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-08-01","518857YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-09-02","11857339","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","Alim M. Ladha, MD","Superior","Participating","Enrollment Complete","2012-09-01","1093935975","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-12-12","","","2025-12-12","Application has been approved effective GM-DATX-Texas CorCare Texas_CorCare@corvel.com VA"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2022-02-15","7653945","","2022-06-21","6/21/2022 - Per follow-up note - 06/13/2022 - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 02/15/2022 under the group and TIN#. PIN: 7653945 . Physical location is on file. Call ref# 6094998732. DCannon"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2025-12-01","","","2025-12-05","Per the December SHP Validation report, provider is enrolled, linked to TIN/location, eff. 12/1/2025.  ML"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Payor Follow Up","","","","2025-12-10","Application is in process. VA"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","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","West Texas Ob/Gyn","IMS","Participating","Application Resubmitted","2022-01-10","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-09-16","","","2025-07-18","Approval ltr rcvd. Effective 09/16/2016. Jen Videan"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2016-09-16","","","2025-07-18","Approval ltr rcvd. Effective 09/16/2016. Jen Videan"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","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","Midland Inpatient Medical Association","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"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Galaxy Health","Participating","Enrollment Complete","2024-09-09","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 9/9/2024. FC"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","Midland Inpatient Medical Association","Superior","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."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","Tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1285175927","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-25","Per UHC rep Jeevanantham via online chat: \"The requested provider is having an active contract under the respective TIN with an effective date of 10/07/2024.\" PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-07","","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2024 for all locations. PIN is the NPI."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","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","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  7/1/2024.  PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Enrollment Stopped","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 07/01/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 07/01/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-08-16","1285175927","","2024-09-19","Rcvd approval ltr. Effective 08/16/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-10-17","CAQH profile reattested on 10/14/25 by another user. Next attestation due on 2/11/26. ML"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Jerome call ref#1407655, provider participating as of 8/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-08-06","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-12","1285175927","","2024-06-12","Per updates@primehealthservices.com,  Effective 06/12/2024, Henry Sirengo is now enrolled with Tax ID: 47-3465832. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare 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","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Stopped","2024-06-10","","","2024-10-02","Longview location was termed 5/2024"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-10","Panel is closed to new enrollments. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-12-02","1073686","","2024-12-20","Received confirmation. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-13","","","2024-09-12","Received email confirmation from BCBSTX, provider is par, eff. 6/13/2024, and linked to TIN/locations. Provider is participating in the following LOB's: •       Blue Choice PPO: 06/21/2024\n•       Blue Advantage HMO: 06/21/2024 \n•       Blue Essentials HMO: 06/21/2024 \n•       Health Select: 06/21/2024 \n•       Medicare Advantage PPO: 06/21/2024 \n•       TriWest T5 TriCare Program: 01/01/2025 . PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  10/07/2024.  PA."]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-12-15","","","2024-01-03","Provider is now linked to the correct location address effective 12/15/2023. MS"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-05-31","1053601344","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO, H&W and GEN networks (GEN is behavioral health) (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","IMS","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","Permian Cardiology Inc.","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","","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2019-08-01","6555230","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Midland Medicine PA","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4060","0008AH","2023-11-01","Received enrollment confirmation eff 11/1/2023. MS"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1760860720","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Midland Medicine PA","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-01","","","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 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","P02614743","EA8735","2023-10-20","10/20/2023  RR PTAN P02614743, and group RR PTAN EA8735, effective 4/1/2021. DCannon"]
["Amber J White, PA","1255614970","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1255614970","","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"]
["Amber J White, PA","1255614970","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1255614970","","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"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-07-08","6703681","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/8/2021 with assigned provider ID 6703681. KFrazier"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","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"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 4/3/2020. AS"]
["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","Permian Digestive Disease Center PA","BCBSTX","Participating","Enrollment Complete","2016-02-12","","","2024-07-31","Received email confirmation, provider is par and linked to TIN & locations. Participating LOBs: Blue Advantage HMO eff. 02/12/2016, Blue Choice PPO, eff. 02/12/2016, Health Select eff 04/01/2017, Blue Essentials HMO eff. 02/20/2016, TriWest, eff 10/01/2016. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 11/1/2021. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","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","","Multiplan","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Omni PPO","Participating","Application Resubmitted","2020-09-01","1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","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","","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-02-01","","","2024-07-26","Received email confirmation provider is PAR and linked to location, eff. 02/01/2024. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","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","","USA PPO","Participating","Enrollment Complete","2024-01-01","","","2024-03-07","Received email confirmation provider is PAR and linked to TIN & location, eff. 01/01/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 2/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","1972506442","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2024 for all locations. PIN is the NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of  2/5/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","For locations: 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 4705 Briarwood Ave 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id effective 07/01/2024.Provider id# 0208158.Physical location is onfile.Call ref# Jaq A 08/05/2025."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","1972506442","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/15/2024 for all locations. NPI# is PIN."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-04-05","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 3/1/2024 with all 5 locations. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 3/1/2024 with all 5 locations. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","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","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1972506442","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1972506442","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1972506442","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-01","Q00681843","DX4335","2024-03-06","Provider is linked. MS"]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-17","Received email confirmation from Marina Martinez (marina.martinez@usamco.com) provider is PAR, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 all locations  participating as of 2/5/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-02-05","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Jerome call ref#1407655, provider participating as of 8/1/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2014-06-10","P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","TriWest HC Alliance","Active","Payor Follow Up","2020-04-03","6418713","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","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","","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","Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Multiplan","Participating","Add Info Submitted","2020-04-03","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Multiplan","Participating","Add Info Submitted","2020-04-03","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Add Info 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","","Caprock (CapStar)","Participating","Add Info 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","Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","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","Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-08-27","Provider participating as of 8/1/2020, listed as PCP, received via roster from Brandy Smith. FC"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-08-27","Provider participating as of 8/1/2020, listed as PCP, received via roster from Brandy Smith. FC"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","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","","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","Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2025-07-30","12740460","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","First Health Coventry","Participating","Add Info Submitted","2020-08-01","3524170","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","First Health Coventry","Participating","Add Info Submitted","2020-08-01","3524170","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Omni PPO","Participating","Add Info 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","","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","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-05-15","1710180666","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1216979","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-09-28","","","2021-12-14","12/14/2021 Update from note made on 10/29/2021. Provider certified as of 9/28/2021. Cbankston"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","IMS complete"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2022-03-11","","","2025-09-15","Received email notification (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/ Location effective 3/11/2022. ML"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","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","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-12-01","2550759","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-08-21","11714128","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-01","1447406137","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","372879ZV0W","519061","2020-04-20","04/20/2020 - Group PECOS enrollment confirrmed this group is listed as provider employer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1710180666","","2025-10-03","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1710180666","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-24","P01732063","DW7662","2020-10-09","10/9/2020 - Was able to confirm RR Medicare enrollment thorugh payer site - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2017-02-06","1710180666","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","341080503","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to group TPI 364596201 and this provider is affiliated with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13",""]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1710180666","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-09-15","4216518","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 9-15-2016 at this service location under a DELEGATED ENTITY - but the payer couldnt identify who - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2016-12-16","1710180666","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1710180666","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1710180666","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","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","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","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","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","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","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","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","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-06-01","6/1/2022 Provider is PAR w/ Multiplan effective 6/20/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","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","Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","13484074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 -  Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","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","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-24","09/24/2020 - moved to completed status - PRIMED DELEGATION - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","1348074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 - Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/11/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","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","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","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","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","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","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","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","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","Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2020-09-01","349777802","165581301","2020-10-01","10/01/2020 - Rec'd emailed confirmation of enrollment from the clinic - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - rec'd email from the payer stating that this demo update has been completed.\" - Stacey Hudak"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-09-29","","","2020-10-23","10/23/2020 Upon review of the self-service portal provider is certified as a non-network provider under Group Tax ID and location is confirmed, effective 9/29/2020. Kimberly Frazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/10/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2016-09-16","03421665","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 9/16/2016;  PLUS - eff 9/16/2016, Star_Kids - eff 10/22/2015.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04",""]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicaid enrollment completed in-house by MCHS.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Ali R Khan, MD","1760714380","47-5554737","TX","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","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-01-07","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-11-01","0843337","","2021-02-26","2/26/2021 Received internal email of approval with an effective date of 11/1/2020 and assigned PID 0843337. KFrazier"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-02-03","2/3/2021 - Rcvd confirmation email from payor stating that provider is participating and linked at location and TIN effective 1/7/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-11-01","003488587","","2021-05-12","5/12/2021 Recevied an email from United_Healthcare_Provider_Operations@uhc.com confirming provider has been loaded under group Tax ID and is now participating effective 11/1/2020 under PR-5736425 with assigned MPIN 003488587. KFrazier"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-07-30","","","2025-12-10","CAQH profile reattested, all information up to date. Next attestation due on 4/9/26. ML"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-01-07","9896886","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 2438435. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-09","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-07","1297078","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-07-09","590902ZV0W","519061","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned PTAN 590902ZV0W effective 7/9/2017. KFrazier"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-07","P01936022","DW7662","2020-12-31","12/31/2020 Confirmed provider is participating under group with RR PTAN P01936022, effective 7/7/2017. KFrazier"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-08-01","","","2020-12-31","12/31/2020 Confirmed via self-service portal, provider is certified as non-network under group effective 08/01/2017. KFrazier"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-24","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 03/24/2020.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","IMS","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","HealthSmart PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Re-Credentialing","2023-05-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing","2023-05-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1871028365","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1871028365","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","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","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","","","2025-08-12","08.05.2025 JJ: Called Aetna @ 1-800-353-1232 to obtain FU status of the provider and s/w Kyle. Per rep, provider is in-network and linked to TIN but eff date depends to each active location. PIN: 6655255. Rep advised that there are 2 locations on file but same address with different eff date: 11/01/2022 and 05/15/2025. Call ref#: 256060620."]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","","","2025-08-12","08.05.2025 JJ: Called Aetna @ 1-800-353-1232 to obtain FU status of the provider and s/w Kyle. Per rep, provider is in-network and linked to TIN but eff date depends to each active location. PIN: 6655255. Rep advised that there are 2 locations on file but same address with different eff date: 11/01/2022 and 05/15/2025. Call ref#: 256060620."]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Omni PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1265872592","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2016-09-22","1265872592","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/22/2016 under the group and TIN#. Provider is delegated to  PE - Midland Inpatient Medical Association. Physical location is on file. Call ref# 5309657469. - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-20","1265872592","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-15","13885700","","2025-11-17","CAQH profile reattested. All information up to date, next attestation due on 3/17/26. ML"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-23","1265872592","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN/Service Location - Stacey Hudak\n\n**rec'd confirmation that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1265872592","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","363331502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-01-23","512648ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider EFF through PECOS group enrollment - Stacey Hudak"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2016-12-15","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-11-17","CAQH profile reattested, all information up to date. Next attestation due on 3/17/26. ML"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2020-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2020-03-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2025-06-25","Per TMHP, license has been updated. Request is closed/approved. Provider is showing active. Jen Videan"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-03","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing","2017-02-23","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-17","553519ZV0W","519061","2020-04-20","04/20/2020 - verified completed enrollment through group PECOS - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-04-03","1013456649","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-05-14","P01880121","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-05-14","579253ZV0W","519061","2020-04-20","04/20/2020 -confirmed provider is EFF through group enrollment in PECOS - Stacey Hduak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1013456649","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312317","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-01","1013456649","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-05-08","1013456649","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 05/08/2020 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-06","11/6/2020 Received email from United_Healthcare_Provider_Operations@uhc.com confirming provider is loaded under Group Tax ID and location for reference number PR-5512953 and assigned internal MPIN 006569937. Kimberly Frazier"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-07-22","As per January roster provider participating as of 8.1.2020 listed as a SPEC. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-06-01","1013456649","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1013456649","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service locatin and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2024-05-08","Rcvd approval ltr. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-11-14","Emailed tricareproviderinquiries@triwest.com for status of contract. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07","761311","0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","0669817","","2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31","1396930426","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1396930426","","2025-10-02","Per tricareproviderinquiries@triwest.com, provider effective 01/01/2025. Jen Videan"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","283737907","079837301","2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01","","","2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04","1396930426","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Vikram Reddy Vadyala, MD","1497985188","47-1394805","TX","Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram Reddy Vadyala, MD","1497985188","47-1394805","TX","Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]

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

{"sheet":"NPISearch","index":3,"n_rows":7,"n_cols":11,"rows_kept":7,"cut":false,"hidden":true,"merged":[]}
["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2025-02-25","Pending Medicare approval. MS"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Provider Load","Provider Load",null,null,null,"2025-02-25"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Medicaid","In Process","Pending Info/Document",null,null,null,"2025-03-13","Per Raymond's intake form his primary taxonomy code is 207RC0200X. Medicaid does not recognize this taxonomy code for NPs. It is used for MD or DOs only. Emailed MQA to advise what taxonomy code should be used as primary for Raymond's Medicaid enrollment. Jen Videan"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2025-04-07","7J6402",519061,"2025-03-13","Recevied welcome letter. MS"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-02-27",null,null,"2025-02-27","2/27/2025 CAQH Reattested-updated TX AP lic and uploaded doc and re-uploaded COI MP107275 doc-dvineyard"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Cigna","In Process","Application Submitted",null,null,null,"2025-02-28","Application submitted via email to Medical Onboarding. MS"]