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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2023-11-22","11/22/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/29/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19","5117734","","2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-17","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01","679507","0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",45126,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19","1046218","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22","","","2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45595,"11483093","","2024-10-30","10/30/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","002539407","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19","382485601","079837301","2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30","1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-11-20","14145595","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-19","12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-09-01","1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2019-08-01","","","2024-08-15","Provider is already enrolled and linked to group effective 08/01/2018. Jen Videan"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","703171","519061","2024-08-15","Provider was already enrolled and linked to this TIN. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-07-01","0044767","","2024-08-23","Provider has been linked and is active under this TIN. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179380","DW7662","2024-08-15","Provider enrolled and active. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-07-17","","","2024-08-15","Provider is active and linked to location. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-13","location is not tricare credentialed, and the panel is currently closed. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattest Profile updated pklika"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01","3094146","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2017 PID # 3094146\ntisha rader"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1104237015","","2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01","1790767119","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete",43270,"","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested",45610,"14218808","","2024-11-14","11/14/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-08-27","08/27/2020 - Rec'd email back from the payer stating \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Coby Robins-Effective 08/13/2018\"  - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18","1104237015","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete",43325,"1104237015","","2020-10-05","Enrollment thru PHCS"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete",43312,"1104237015","752133441","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kim Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete",42995,"1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09","","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","TriCare Standard","No Enrollment Required","No Enrollment Required","","","","2024-04-01","Enrollment is set up as an ambulatory enrollment and providers can not be added to it. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",45208,"","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted",45208,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",45236,"","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","IMS","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete",45208,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45311,"","","2024-01-09","Received confirmation via self service portal. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Wellmed","In Process","Payor Follow Up","","","","2024-07-08","Sent email to payor requesting status update. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete",45328,"","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","IMS","Participating","Enrollment Complete",45328,"","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","IMS","Participating","Add Info Submitted",45328,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45292,"","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",45292,"","","2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete",45328,"","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Multiplan","Participating","Enrollment Complete",45328,"","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Multiplan","Participating","Add Info Submitted",45328,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed eff 1/2/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete",45328,"","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06","","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21","","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna","Participating","Enrollment Complete","2024-02-01","0446524","","2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-11-01","","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Medicaid","Participating","Enrollment Complete","2024-09-03","","","2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06","","","2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","In Process","Add Info Submitted","","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete",45407,"","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted",45383,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","First Health Coventry","Participating","Add Info Submitted",45383,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",45208,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06","","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Aetna","Participating","Enrollment Complete","2024-02-06","","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01","0446524","","2023-12-04","Received approval email effective 12/01/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-11-03","11/3/2023 CAQH profile maintained by practice.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-01","8096880","","2024-01-03","Received confirmation. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. PA."]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to the group eff 11/6/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","008167479","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Rcvd email confirmation from Jessica Bess at Multiplan that November roster has been processed and provider is PAR w/ group effective 11/6/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - 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","PE - 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","PE - 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","PE - 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","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45183,"","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008092273","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 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","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-10-13","","","2024-05-02","Received email from Marcus Wester (mwester@humana.com) provider has been linked to location, eff. 10/13/2023. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",44682,"2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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",45323,"","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted",45323,"","","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",45323,"","","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","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45323,"6819516","","2024-01-09","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",44925,"","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","Application submitted via portal. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Medicare","","","","2024-11-26","Group application to add this location was submitted. Once approved, the provider will be linked to this location. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45047,"","","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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45047,"","","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","PE - 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","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 1/1/2020. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1841780806","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45139,"","","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","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","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","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45201,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",44743,"","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2022. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","6910036","","2023-09-19","09.19.2023 S/W Joe of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 06/19/2023. PIN: 6910036. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163696629. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-06-13","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45440,"","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45499,"","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete",44725,"","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-11-18","Submitted location add via portal, case# 11715618. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02"," Confirmed enrollment via Tricare portal. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Provider is confirmed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2024-11-26","Application was submitted at the group level. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45201,"","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45047,"","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 05/17/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45440,"","","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","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44745,"","","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-28","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44713,"","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","","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","PE - 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","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-28","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","00008092273024","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","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","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["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","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-07","","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","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","PE - 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","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","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","PE - 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","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","",45443,"Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-06-19","6819516","","2023-09-19","09.19.2023 S/W Sofie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 6819516. Service location is on file. Call ref#:SofieS09192023."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-26","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - 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","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45138,"","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45138,"","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","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","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1225283963","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider participating as of 5/25/2023 via roster. FC"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-10-19","Received enrollment confirmation. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2023-07-01","","","2023-09-15","Received confirmation email with effective date. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-12-28","12/28/2023 Per UHC web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-19","9/19/2023 - Received email that delegation roster has been completed.  Provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-12-04","","","2024-12-04","12/04/2024 new COI uploaded pklika"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","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","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2023-04-25","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Payor Follow Up","2023-04-14","","","2024-05-16","5/16/2024 Payor has incorrect address, updated address submitted via delegated roster on 5/15/2024. FC"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2024-07-25","Revalidation approval ltr rcvd. Effective 05/01/2023. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing",45030,"","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27",""]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2018-07-31","1740542034","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Pending Info/Document","","","","2024-11-27","Still pending surrogacy. Client notified. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","","Medicare","Participating","Pending Info/Document","","","","2024-11-27","Still pending surrogacy. Client notified. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1740542034","","2020-06-10","06/10/2020 - Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2018-09-01","1740542034","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-12-06","","","2024-09-09","Confirmed provider is linked to this location. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3165726","","2020-03-20","03/20/2020 - Recd email from the payer stating this provider is effective under PID# 3165726  - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1740542034","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 8/1/2018. Physical Location is on file. Provider ID #6404238. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2018-08-01","","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-05-20","1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Pending Info/Document","","","","2024-11-27","Still pending surrogacy. Client notified. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","","Medicare","Participating","Pending Info/Document","","","","2024-11-27","Still pending surrogacy. Client notified. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2020-01-05","412587401","325373401","2024-09-09","Per TMHP provider still showing effective/active and linked 01/05/2020. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-05-13","1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312287","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-07-02","","","2024-09-09","Provider has been confirmed linked to this location. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2024-08-29","Received confirmation from Cassandra Dunagon provider is participating with all products. FC"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-08-01","387144401","364596201","2023-12-19","Revalidation approval letter rcvd. Effective 08/01/2018. Jen Videan"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1649462987","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","2506877","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2506877 - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1649462987","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","685085","519061","2020-04-22","04/22/2020 - found EFF info through group PECOS enrollment - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1649462987","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-08-19","8/19/2020 - Rec'd a new spreadsheet from Baylor Scott & White after they merged databases with First Care. Updated the effective date and this provider is showing up affilaited with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179384","DW7662","2020-04-22","04/22/2020 - Confirmed provider EFF info through payer portal - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-02-12","1407149883","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1407149883","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1407149883","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-09-01","P02262526","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 09/01/2018 with provider number P02262526. Attached welcome letter to payor line\n--tisha rader"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-08-27","1407149883","","2020-09-23","09/23/2020 - Reviewed follow up complete note and moved to completed status - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","3060094","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3060094 - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-09-01","377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1407149883","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-09-01","691156","519061","2020-02-19","02/19/2020 - Rec'd PECOS login .Signed in to find that this provider is successfully enrolled with Medicare/MIMA as of 9-1-2018. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1407149883","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-07-30","7/30/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/27/2020.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-06-03","Per Aetna rep Irish G, 1-800-353-1232, reference #6194100173, provider is  PAR, effective 3/11/2024, linked to TIN and location. PA"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-04-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective  4/15/2024, and is linked to the TIN and location. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-02-12","7487489","","2024-04-05","Received confirmation of enrollment via email. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45364,"","","2024-08-08","Provider PAR with Star, Star kids, and Star + eff date 3/13/2024 as per roster received from Cassandra via email. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-12","Location is not Tricare Credentialed, panel is closed. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-08-08","Provider participating as of 4/1/2024 listed as Pediatrics, spoke to Tash call ref#11607782. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2024-03-12","","","2024-04-29","Provider is linked to this location eff 3/12/24. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-28","","","2024-08-16","Received confirmation from Mary Rodriguez via e,mail, provider participating as of 12/28/2023. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45362,"","","2024-08-08","Received confirmation provider is PAR and linked to TIN/location, eff. 3/11/2024. Product roster uploaded. PA."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete",43595,"","","2024-07-24","Approval Ltr rcvd. Effective 05/10/2019. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2019-04-04","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-22","Revalidation approval ltr rcvd. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","380896603","331090601","2020-07-15","07/15/2020 - logged into TMHP and found that this provider is EFF - TPI 380896603 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1588857874","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-09-01","1588857874","","2020-02-10","02/10/2020 - Rec'd confirmation from payer that this provider is EFF at 5615 Deauville, Ste 220 through a DELEGATED PAYER (Permian Basin Healthcare Network) and linked to the following products: STAR, HEALTH FOSTER CARE, STAR, STAR PLUS, CHIP RSA,\nSTAR KIDS, CHIP, CHIP PERINATE, also EXCHANGE (exchange only since 1-1-2014; non par) All other products are PAR since 9-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Re-Credentialing","2019-05-01","2650428","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2019-05-10","","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 4-4-2019 under a DIRECT CONTRACT at this service location."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-03-01","P02232681","DU5783","2020-02-21","02/12/2020 - Found effective info through payer site stating provider is PAR with group PTAN:  DU5783 EFF 3-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete",43616,"","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1588857874","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-04-27","1588857874","","2024-05-07","Provider active with Corvel. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1588857874","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete",43586,"","","2020-09-04","Provider is participating under group Tax ID and correct location. Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-04-19","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/6/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1588857874","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2019-05-31","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-19","1588857874","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete",45462,"1164778767","",45471,"Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019. – Archie Candiasan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","","","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-09-04","Emailed Brandhi_Wilson-Woods@Corvel.com for status. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective 5/1/2019 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1164778767","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-11-18","","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2024-02-21","Rcvd revalidation approval ltr. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Re-Credentialing","2019-05-01","3039403","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2019-05-31","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete",43952,"","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete",43622,"1164778767","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete",43770,"1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2024-04-05","","","2024-08-27","Provider participating as of 4/5/2024 listed as a SPEC received via roster from Brandy Smith. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-06-06","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete",43770,"1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21","13859704","","2024-12-04","12/04/2024 Request location removed, requested location added pklika"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-06","Location added under group record, but is not a Tricare Credentialed location. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/01/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Provider Load","","","","",""]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Sedgwick","Participating","Provider Load","","","","",""]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Ste. 240. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",43586,"","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44286,"2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43753,"","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",43616,"1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","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","","Medicare","Participating","Enrollment Complete","2019-09-01","842726","270548","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS   Eff 8/2024, Symplr will now manage. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Pending Info/Document","2019-09-01","842726","270548","2024-11-27","Still pending surrogacy. Client notified. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Medicare","Participating","Pending Info/Document","2019-09-01","842726","270548","2024-11-27","Still pending surrogacy. Client notified. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2019-09-01","","","2024-07-08","Revalidation approved. Effective 09/01/2019. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","In Process","Confirm Par Status","","","","2024-09-11","Emailed SPNEAST@sedgwickcms.com for par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1144665233","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 3303866 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-12-05","","","2024-09-09","Provider is linked to this location. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Enrollment Complete","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","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","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45078,"","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2019-07-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02","1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15","1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-05","","","2023-10-20","10/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-07-01","5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/5/2023.  PID # 7585417.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-08-11","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45082,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete",45082,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",45082,"","","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",45082,"","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",43691,"1932541406","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",45082,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Add Info Submitted",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",43586,"397298601","079837301","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43628,"1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete",43628,"1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",43628,"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",43628,"1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",43831,"","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",43586,"1932541406","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43586,"1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44794,"","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",43628,"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",43628,"1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted",43628,"1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted",43628,"1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-05","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-21","Revalidation Approval Ltr rcvd. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-04-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21","14530139","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1528619525","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","403199901","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312274","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11","1528619525","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-07-01","6345073","","2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-10-01","869041","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01","09832854","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-07-27","IMS complete"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 12/30/2019.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-02","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13","1528619525","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44801,"1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - 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","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-20","14485629","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1366762874","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-17","","","2023-11-29","Per TMHP location has been approved. Effective 02/26/2023. Jen Videan"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","","","","2024-03-21","3/21/2024 Provider effective as of 5/4/2020 via Wellpoint roster. FC"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-01-01","0970113","","2023-12-19","Received confirmation effective 1/1/2023. MS"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete",44105,"","",44414,"8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-02-11","1B4358","320497","2020-04-23","04/23/2020 - Found porivder as EFF under gorup enrollment through PECOS - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2020-06-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective  6/1/2020 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-08-12","1447882915","","2020-09-24","09/24/2020 - moved to completed status after reivewing follow up complete - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922008234","","2020-07-27","IMS complete"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-07-19","","","2021-03-15","3/15/2021 Rcvd roster from Amerigroup listing provider effective and participating under TIN effective 7/19/2019.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2014-12-01","1922008234","West Texas Physicians Alliance","2020-07-06","07/06/2020 - Rec'd email from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Marriner, Cindy:\n\nNetwork:  MPI, MPI Auto and MPI WC\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 5026 - West Texas Physicians Alliance\n\nNetwork: PHCS\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 23655 - West Texas Physicians Alliance\n\nNetwork: Beech St.\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 52669 - West Texas Physicians Alliance\" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750796009","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1750796009","","2020-09-02","09/02/2020 - Rec'd email from the payer confirming this location add has been made - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-28","3961479","","2020-09-01","09/01/2020 - moved to completed status after getting an email from the payer stating \"Your effective date is 08/28/2020. Your provider identification number is 3961479. \" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3169156","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","3961479","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 3961479. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - 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","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","3961479","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 3961479. KFrazier"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-05-23","13574654","","2022-03-23","03/23/2022 Per follow-up note - S/W Asia of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 5/23/2017 under the group and TIN#. Provider ID# 13574654.Physical location is on file.Call ref# 7943427.-DCannon"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-01-18","1447701602","","2020-03-24","3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW JR, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 1/18/2018. DIRECT CONTRACT. Location is on file. Call ref# 5192494651.--tisha rader"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","In House Enrollment","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer site - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2019.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2015-08-20","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 8/20/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","2020-09-14",""]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","1154767234","","2020-06-30","6/30/2020 - Receved email spreadsheet from the paayor confirmg that this provider is EFF this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",42284,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/7/2015.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","1891931341","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","","","2020-09-14",""]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/1/2020.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2019-02-19","1891931341","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","5244447","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 5244447. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",44348,"","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-10-21","1205299922","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","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."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-10-21","","","2020-09-14",""]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-08","1184265050","","2020-07-21","07/21/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 8, 2020 1:42:08 PM. Your request was assigned reference number PR-5374823 .\" - Demo update completed - Stacey Hudak"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-01-15","","","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 1/15/2020.  DCannon"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-03","9835482","","2020-08-04","8/4/2020 - Rec'd email from the payer stating \"Your effective date is 08/03/2020. Your provider identification number is 9835482. \" - Stacey Hudak"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Omni PPO","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","TX","PE - Midland Medicine PA","Boon Chapman","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","TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-06-01","007772537","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2022.   MPIN# 007772537.   DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete",44756,"","","2022-07-21","7/21/2022 Per Tricare portal provider is PAR and linked to group TIN/ new location effective 7/14/2022.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2023-07-01","","","2023-08-11","08.11.2023 S/W April of First Health @ 800-226-5116. Per rep, provider is showing par and link under the Group and TIN with an Effective date 07/01/2023. Provider ID 3709511. Service location is on file. Call ref#:725002.-Danico Gabriel Melendres"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-06-23","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 6/23/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750539268","","2020-07-27","IMS completed"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - 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."]
["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","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 10/4/2024. AS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-04-22","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/22/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",43435,"3191800","","2023-09-20","09.20.2023 S/W ShannonD of First Health @ 800-226-5116 and transferred me over to Melanie. Per rep, the provider is in network with First Health for the state of TX and linked to the group and TIN# effective 12/01/2018. No next recredentialing date available. PIN: 3191800. Servicing location is on file. No payer# available. No call ref# available. - Willie Ravas"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","","Aetna","Participating","Enrollment Complete","2019-10-01","6875567","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of10/1/2019. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-09-19","9/19/2023  Provider is PAR and linked to group/locations effective 6/1/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2018-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","6875567","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2015. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted",45047,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2020-10-05","10/5/2020 - this is a facility contact for urgent care. No provider credentialing/enrollment needed - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",43709,"1528430865","","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Provider is linked to the Briarwood location effective 7/28. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Andrews Hwy linked eff 10.26.2023"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312302","","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"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - 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","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - 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","PE - ADA Adult and Children Family Clinic LLC","Omni PPO","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-07-27","IMS complete"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Medicare","Participating","Enrollment Complete","","","","2023-10-12","Confirmed the new location has been added to the group enrollment. MS"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete",44044,"","","2020-08-25","Confirmed provider is participating under delegation effective 8/1/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","1538571609","","2020-09-16","09/16/2020- Rec'd spreadsheet from the payer confirming this provider/service location have been made effective under the primed roster - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete",44197,"","","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","PE - Permian Physician Services","Humana","Participating","Enrollment Complete",42824,"1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-03-30","","","2020-09-14",""]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete",45128,"","","2023-08-15","Per Michelle Killough @ PSWCA Dr. Molina is par effective 07/21/2023. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2017-08-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 08/01/2017 | Priscilla A."]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22- Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-26","","","2020-09-14",""]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","6163991","","2020-08-18","8/18/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete",42662,"1972942209","","2020-08-19","08/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to this TIN/service location and networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network  - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","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,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727805","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster from Amerigroup confirming that provider is PAR and linked to group TIN/location effective 8/5/2020.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete",43709,"1083867147","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2023-05-29","Per Coventry portal provider is enrolled. Jen Videan"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete",45399,"","","2024-04-29","Rcvd acceptance letter. Provider effective 04/17/2024. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 9/26/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2015-01-01","","","2021-07-09","7/9/2021 Called Humana at 800-626-2741 spoke w/ Taylor, call reference # 2000191481297 he confirmed that provider is PAR under TIN and location effective 1/1/2015.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2019-09-01","6837080","","2020-12-04","12/4/2020 Rcvd email from Cigna confirming provider is PAR at location.  PID: 6837080; TIN: 263789190\nEffective date: 09/01/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2022-04-01","","","2022-07-01","7/1/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-03-02","","","2022-04-18","4/18/2022 Per Tricare portal, provider is par as of 3.2.2022. Cbankston"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete",43770,"7004909","","2020-09-08","09/08/2020 - Reviewed the last note and the spreadsheet sent by the payer. THis can be made EFF - Stacey Hudak"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-06-19","","","2024-07-22","Approval ltr rcvd. Effective 06/19/2024. Jen Videan"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-06-21","7565313","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 6/21/2021 and assigned provider ID 7565313. KFrazier"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - 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"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2014-04-01","","","2023-05-02","5/2.2023 Per confirm par status note.   Per rep, provider is showing participating with an effective date 4/1/2014 and link under the Group and TIN. Provider ID 2609103.  Service location is on file. Call ref#:610334. DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1184035313","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the delegated primed roster - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2020-06-22","","","2020-10-27","10/27/2020 Confirmed provider is certified as a non-network provider. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",44029,"","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  7/17/2020. DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2017-07-26","1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete",42461,"311323YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd documentation from the clinic that this has been approved through PECOS - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","TriCare Standard","Participating","Enrollment Complete","1996-12-03","","","2020-10-23","10/23/2020 Upon review of the self-service portal, provider is certified as a non-network provider, as well as participating under group with location. Kimberly Frazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","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","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2016-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2016 | Priscilla A."]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1306928098","","2020-08-04","8/4/2020 - Rec'd email from the payer confirming this provider is enrolled/linked to this group NPI - Stacey Hudak\n\n8/20/2020 - Rec'd a spreadsheet from the payer stating this provider is affilaited with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","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"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2017-01-17","1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - 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","PE - 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","PE - North Big Spring Family Care","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3625881. Next recredentialing date is every 3 years (12/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Maria Montero, MD",1508218843,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2020-11-05","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and location effective 11/5/2020. Also states action needed, which is typically the payor notification to process a new back-ground check. KFrazier"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1285065946","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Add Info Submitted","","","","2024-11-20","Submitted a new Supervising Phys for the enrollment. MS"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up","","","","2024-11-06","Will resubmit on November delegated roster provider not listed on roster provided by Cassandra Dunagon. FC"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-10-10","7341570","","2024-10-11","Received confirmation email. MS"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-11-19","Per Humana rep at 1-800-626-2741, ref# 2000419053040, request to link provider under TIN/location combination is still pending. Per rep, \"request will take 60-90 days from submission date - please allow more time.\" PA."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-10-08","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","In Process","Application Submitted","","","","2024-11-15","Submitted location add via delegated roster submission. PA."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44222,"1312371","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-10-13","","","2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Provider Type Not Enrolled","Provider Type Not Enrolled","","","","2021-09-07","9/7/2021 Rcvd email from LaNetrice Myart @ USA PPO that registered dieticians are not credentialed/enrolled through USA PPO.  There fore enrollment will be stopped for this provider.  DCannon"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","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 2/1/2021.  DCannon"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete",43748,"3309747","","2023-02-16","02.16.2023 S/W Theressa of First Health @800-226-5116. Per rep, provider is in network and linked under the TIN effective 10/10/2019. Don't have recredentialing date and Payer#. Provider ID# 3309747. Physical location is on file. Call ref# 547404. - Mary Rose Acebedo"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  9/2/2021. DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","","","2020-12-18","12/18/2020 This is an RHC facility and does not require provider enrollment. KFrazier"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete",44203,"6945139","",44304,"4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicaid","Participating","Enrollment Complete","2023-12-12","","","2024-03-20","Welcome ltr rcvd. Provider effective 12/12/2023. Jen Videan"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-02-01","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 2/1/2024, and is linked to the TIN and location. PA."]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","",45622,"Application was submitted at the group level. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","","","","2024-11-08",""]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete",44136,"420200401","205408201","2021-04-12","4/12/2021 Upon review of TMHP portal, provider has been assigned TPI 420200401 under group TPI 205408201 effective 11/1/2020. Also emailed Stacy Salazar confirming a request for linkage from our TMHP account has been submitted for all fields of her access. KFrazier"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-02-08","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 02/08/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-03-15","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 3/15/2021. DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete",44281,"","","2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 03/26/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN has active 400TX DCN.  TIN has association of RHC.\""]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Superior that provider is PAR and linked to group TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2021-07-08","","","2024-02-28","Re-Cred has been completed. eff 7/8/2021. MS"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","No Enrollment Required","No Enrollment Required","2021-04-02","","","2022-04-01","No enrollment required due to this being a RHC. DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Re-Credentialing",44292,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-12-15",""]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-11","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45474,"","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45474,"","","2024-10-25","Received confirmation from Brandy Smith via delegated roster provider participating as of 7/1/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45487,"","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-10-09","","","2024-10-10","Approval ltr rcvd. Effective 10/09/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45463,"","","2024-06-18","Received email confirmation provider is now par with BCBSTX, eff. 6/20/2024, participating in the following networks:\n\nBAV - Blue Advantage HMO\t\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials\t\nPMC - Medicare Advantage PPO"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-18","Submitted via delegated roster on 7/15/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-11","5155848","","2024-06-11","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-11","","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45553,"","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45474,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45474,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45454,"","","2024-08-30","Approval Ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-06-17","Provider has been loaded to 5/6 locations. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45497,"","","2024-10-02","Per the Tricare portal, she is linked to this location. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","6S4338","423838","2024-06-17","Received welcome letter. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45422,"6S4338","423838","2024-06-17","Received welcome letter. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45590,"","","2024-11-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-11-21","","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-23","","","2022-06-11","6/11/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 3/23/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2021-05-10","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2021-05-15","6230006","","2021-09-16","9/16/2021 Received an email from Rep Jamie Roberts at robertsj6@aetna.com confirming provider is participating under group Tax ID and location effective 5/15/2021 with assigned PIN number 6230006. KFrazier"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00110005","CE1588","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # Q00110005 effective 7/1/2021.  DCannon"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","2024-04-24","1215213970","","2024-06-11","Approval ltr rcvd. Provider effective 04/24/2024. Jen Videan"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Amerigroup","Participating","Enrollment Complete","2024-05-23","","","2024-06-19","As per May WellPoint roster, Andrews Hwy location eff as of 5/23/2024. FC"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-07-21","","","2024-01-25","During Tricare audit, it was found this provider is credentialed and in network MS"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-08-28","Received confirmation email of last name update. MS"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2021-09-01","6764944","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","HealthSmart PPO","Participating","Enrollment Complete",45323,"","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45225,"","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-01","1R4342","423838","2021-07-13","7/13/2021 Received approval notice from payor with assigned provider PTAN 1R4342 effective 7/1/2021, under group PTAN 423838. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 6/12/2023. AS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45047,"","","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2021-10-08","","","2024-02-15","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-01","","","2023-09-08","Provider is currently enrolled with all locations under WesTex. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-04-15","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 04/15/2020 . PA"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 2/1/2024. AS"]
["Jeffery Dickson, NP",1851865067,"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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45201,"","","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-08-13","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-03-29","","","2024-05-29","incorrrect username and password"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-03-29","","","2024-05-29","incorrrect username and password"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","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","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-08-13","","","2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44536,"","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44440,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-04-18","","","2024-04-22","Approval ltr rcvd. Provider effective 04/18/2024. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2023-10-02","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","Caprock (CapStar)","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","","Omni PPO","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Wellcare","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Cigna","Participating","Enrollment Complete","2023-01-03","","","2023-08-14","08.14.2023 S/W Tom of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 01/03/2023. Provider ID 9669133. Service address is on file. Call ref#:TomF08142023.-Danico Gabriel Melendres"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03","","","2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Neil P Doctor, MD",1619322492,"92-0763047","TX","PE - VYVO Therapeutics","Humana","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. PA."]
["Neil P Doctor, MD",1619322492,"92-0763047","TX","PE - VYVO Therapeutics","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. PA."]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-06","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-12","2G2470","0008AH","2023-07-19","7/19/2023 Per PECOS provider is PAR and linked to group and location 4214 Andrews Hwy, Ste. 102.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-06-06","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Add Info Submitted","2023-04-27","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-06","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-07-26","","","2024-02-13","Confirmed Tricare Prime enrollment. MS"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Add Info Submitted",44501,"6261482","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","","Amerigroup","Participating","Add Info Submitted","2021-11-01","12182506","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Add Info Submitted","2022-12-01","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Add Info Submitted","2021-11-01","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-10-27","0227001","","2021-10-28","10/28/21 Received email from DiscoverCigna@information.cigna.com, application to participate in the Cigna network has been approved. Effective date is 10/27/2021. Provider identification number is 0227001 Cbankston"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-11-05","","","2022-02-24","2/24/2022 Per Tricare portal provider is PAR an linked to group TIN/location effective 11/5/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","","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","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-11-18","","","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 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-11-18","13800916","","2022-04-23","4/23/2022 Per follow-up note - Provider's NPI is on file and participating under the group and TIN# effective 11/18/2021.  Physical location is on file.  Provider ID is 13800916.   DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete",44518,"6014588","","2022-02-24","02/24/2022 Per follow-up note from 2/17/2022 Provider NPI# is on file for the provider and is participating effective 12/01/21 under the group and TIN#. PIN 6014588. Physical location is on file. Ref# 6075311576. DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","","Aetna","Participating","Add Info Submitted","2021-11-18","6014588","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2022-01-10","12764584","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID # 12764584.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","","Omni PPO","Participating","Add Info Submitted","2022-01-10","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete",44607,"","","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"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","No Enrollment Required","2021-12-01","","","2021-11-09","11/9/2021 Provider is currently certified as non-network so no application is needed. KFrazier"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, 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"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete",45231,"","","2023-11-14","Approval Ltr rcvd. Provider effective 11/01/2023. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete",44909,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete",44909,"","","2024-02-28","Re-Cred has been completed. eff 12/14/22. MS"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete",44690,"","","2022-07-23","7/23/3033 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Participating","Enrollment Complete",45352,"","","2024-08-13","Received confirmation via email from Janeil Chuck from Coventry, provider participating as of 3/1/2024. FC"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2763424","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2763424.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-02-21","4120898","","2022-06-21","6/21/2022 - Per follow-up note - NPI# for the provider is on file, shows par under the group and TIN#, effective 2/21/2022, the physical location is on file and the Provider ID is 4120898.  Call ref # Camaria6142022. - DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267321","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267321 - effective 2/21/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44682,"","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44687,"","","2024-01-03","Provider is now linked to the correct address effective 12/14/2023. MS"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44682,"","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-05-13","6105828","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 05/13/2022.  PA"]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete",45509,"","","2024-10-07","Received confirmation via email from Jessica Bess, provider participating with Medicaid product effective 8/5/2024. FC"]
["Megan E Rosa, PA",1720698640,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-13","Pending location add to Medicaid group record. In process. Jen Videan"]
["Megan E Rosa, PA",1720698640,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-04","Panel is closed to new location enrollments. MS"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete",44690," 3558017","","2022-07-28","7/28/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-22",""]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete",45462,"1790251031","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2E8661","320497","2022-06-21","6/21/2022 Rcvd Medicare approval letter.  PTAN # 2E8661 - effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Add Info Submitted","2022-06-01","","","2024-11-15","Submitted request to add provider to CHIP via delegated PACT submission. PA."]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group 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."]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2022-05-09","6227554","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete",44690,"","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",44690,"","","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 5/9/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","CAQH","Participating","CAQH Reattested",45600,"","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Rail Road Medicare","Participating","Enrollment Complete",44682,"P02660539","EB8061","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # P02660539 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","First Health Coventry","Enrollment on Hold","Enrollment on Hold","","","","2023-11-22","11/22/2023 Per previous note - provider is part of a delegated group and the provider would need to contact that delegated group to make any updates/changes.   Will reach out to MQA for assistance. DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-09","Received panel closed letter. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-20","","","2022-08-10","8/10/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/20/2022.    DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-09-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","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.\""]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete",44826,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1871250191","","2022-10-20","10/20/2022 Rcvd TMHP approval letter provider is PAR effective 8/28/2022.  TPI # 1871250191.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-08-01","3730894","","2023-10-19","10.17.2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is showing as participating and link under the Group and TIN with an Effective date 08/01/2023. Provider ID 3730894. Service location is on file. Call ref#:788770.-Danico Gabriel Melendres"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","8355571","","2022-11-30","11/30/2022 Per follow-up note - Per rep, provider is on file and participating. Link under the group and TIN effective 11/15/2022. Location is on file. Provider ID is 8355571. Next recredentialing date is 11/4/2025.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","TriCare Standard","Participating","Enrollment Complete","2022-09-23","","","2023-01-05","1/5/2023 Per Humana Military/Tricare portal provider is now a PAR Tricare Certified provider effective 9/23/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Rail Road Medicare","Participating","Enrollment Complete","2023-01-25","P02703383","","2023-08-21","Confirmed enrollment. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","CAQH","Participating","CAQH Reattested","2024-11-27","","","2024-11-27","11/27/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete",44866,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",44830,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete",44823,"","","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","PE - Permian Physician Services","CAQH","Participating","Pending Info/Document","2024-11-04","","","2024-11-04","11/04/2024 Can't Reattest Liability on file is expired"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","2022-08-01","","","2023-07-12","Per Neris at TMHP Ticket# 46628797000 Dr. Eby is par and linked to Permian Physician Practice effective 08/01/2022. TPI# 406528603. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted",44893,"","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted",44893,"","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",45115,"","","2024-10-31","Approval ltr has been rcvd. Location has been added to provider's profile effective 07/08/2023. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2022-11-28","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-03-18","","","2024-05-15","Group record has been updated, so individual record is auto updated. MS"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-10-31","","","2023-03-08","3/8/2023 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","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",44998,"","","2023-03-28","3/28/2023 Rcvd Tricare certified approval letter.   Provider is TRICARE-certified in Texas effective  3/13/2023.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - 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","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-10-31","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-10-31","","","2022-12-15","12.15.22 Called Aetna @800.353.1232 and spoke with rep. Gelo who confirmed provider is participating effective 10/31/2022 at service locations and Tax ID. No recred date given per rep. Provider # 8624593. Call ref# 6124264748. ABoles"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete",45271,"8365374","","2024-01-02","Received confirmation of approval. MS"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45016,"3671302","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 3/31/2023. Provider ID 3671302. Physical locations are on file. Call ref#:773110. - DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","","First Health Coventry","Participating","Enrollment Complete",45016,"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","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45201,"","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy 5/6/2024\n616 N Main St & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45103,"007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-03-31","3671302","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45170,"","","2023-09-26","Confirmed provider is loaded at the Briarwood location effective 9/1/23. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45016,"","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-03-31","","","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 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete",45016,"","","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 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-17","Q00521373","","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/17/2023. PID # Q00521373.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45002,"2V9975","","2023-08-25","Per PECOS provider is PAR and linked to group/locations effective 3/17/2023.  PID # 2V9975.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45135,"","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-06-09","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge Rd Odessa, TX 79765, 4705 Briarwood Ave Midland, TX 79707 and 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 effective 08/01/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45060,"","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45474,"","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45376,"1184108664","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-12-18","Per Michelle Killough provider is effective 11/17/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-05-01","","","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45499,"","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2024-11-12","11/12/2024 location added, see other CAQH tab for exp dates"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","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 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45176,"","","2023-09-07","Rcvd welcome letter from Karina Garcia. Provider effective 09/07/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45217,"","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45119,"","","2023-07-12","Received email confirmation from Jacki Hipolito. MS"]
["Stacey Jo Guse, NP",1184108664,"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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-05-06","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/4/2024\n6950 Eastridge Rd, 4705 Briarwood Ave, 616 N Main St. eff. 6/12/2023\n6301 Andrews Hwy 5/6/2024.\nAS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff. 05/01/2023. PA."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-05-01","","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024 except Longview and Greenbriar. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2023-03-01","2S7645","0A3812","2023-05-04","5/4/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations effective 3/1/2023.  PTAN# 2S7645.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2023-05-08","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-08-15","Per Michelle Killough at michelle.killough@pswca.org, Dr. Daye is par effective 07/21/2023. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-09-01","","","2024-08-28","Approval ltr rcvd. Effective 09/01/2024. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-10-01","10/01/2024: Medicaid did not approve retro effective date request for 4214 Andrews Hwy Ste 109 Midland TX 79703 to be changed from 10/02/2023 to 06/18/2023. Effective date still showing 10/02/2023. JV"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",45078,"","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Payor Follow Up","2023-06-01","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-16","000887435","","2023-10-05","10/5/2023 Rcvd copy of participating network list with effective dates for provider.  Provider is PAR with UHC effective 9/16/2023.  (see copy of report uploaded in attachments) DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","","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"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-08-01","","","2024-05-20","5/20/2024- Spoke to Max C call ref# 6192813282 N Main location effective as of 8/1/2023, provider listed as a SPEC. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45146,"","","2023-11-09","Received confirmation of Andrews Hwy location eff 11/6/2023. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45146,"","","2023-08-23","Confirmation the provider has been linked to the Briarwood and Longview locations. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45146,"","","2023-11-09","Received confirmation of Andrews Hwy location eff 11/6/2023. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-08-01","8219691","","2023-09-19","09.19.2023 S/W Kris of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 8219691. Physical locations are on file. Next recredentialing date is on 08/01/2026. Payer# 60054. Call ref# 6163714512. - Willie Ravas"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-11-15","","","2023-11-27","Rcvd approval letter. Provider effective 11/15/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-08-01","","","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 except Longview location. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-08-01","","","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 except Longview location. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45139,"","","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"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45139,"","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","3607159","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently enrolled. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45139,"","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-01","00008830908","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00008830908.   DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-01","00008830908","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00008830908.   DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45219,"","","2023-10-19","10/19/23 Enrollment complete and participating with all products.  Effective date 10/20/23"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-06-19","3674906","","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"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-08-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-10-26","Rcvd welcome letter from Karina Garcia at Corvel. Provider is effective 10/26/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","","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"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-11-18","Submitted location add via portal, case# 11715618. PA."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-04",""]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45139,"","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Medicare","","","","2024-11-26","Group application to add this location was submitted. Once approved, the provider will be linked to this location. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - 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. 8/1/2023\n3490 E Yukon Rd eff. 9/1/2024. AS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave Midland, TX 79707, 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 and 6950 Eastridge Rd\nOdessa, TX 79765 effective 09/01/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45089,"","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to Eastridge 10/9/23, Longview 8/24/23 and Andrews Hwy.  1/10/24  MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Re-Cred application approved. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45107,"","","2024-04-25","4/25/2024 provider enrolled as of 6/30/2023 via roster. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45087,"Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45200,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","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","Application Resubmitted","2023-06-01","2243378","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2023, and linked to 616 Main St. location. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","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."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-05-29","","","2024-08-01","missing current CAQH username and password"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-19","003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45419,"","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-06-12","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","App submitted via Tricare portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Medicare","","","","2024-11-26","Group application to add this location was submitted. Once approved, the provider will be linked to this location. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-06-01","2243378","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-06-12","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 wxcept Longview location. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2024-01-22","1/22/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 6/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - 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."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","1073983193","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested",45600,"13954674","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2024-08-23","Briarwood Location: Provider is active and linked to this location eff 7/9/2024. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Payor Follow Up",45139,"19103471","","2024-01-16","1/16/2024 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of August roster.  Have not received responses from previous requests.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2023-05-29","853821","","2024-02-12","Received completion notice. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-05-29","2V0556","00608K","2023-06-22","Received confirmation of COI. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete",45170,"1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete",45352,"3480191","","2024-04-08","Per First Health rep Giovann, 1-800-226-5116, ref# 1001519, provider is PAR and linked to both locations (5000 Briarwood and 5424 19th Str), eff. 3/1/2024. PA."]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Gallagher","Participating","Enrollment Complete",45088,"","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","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","PE - 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","","Humana","Participating","Enrollment Complete",45317,"","","2024-05-22","5/22/2024 Provider participating as of 1/26/2024 listed as PCP spoke to Jen R. call Ref#2000387504047. FC"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Superior","Participating","Enrollment Complete",45170,"","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Medicaid","Participating","Enrollment Complete","2023-06-01","","","2024-01-05","Welcome letter rcvd. Provider effective 06/01/2023. Jen Videan"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Add Info Submitted",45177,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Add Info Submitted",45177,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","BCBSTX","Participating","Enrollment Complete","2023-06-29","1609921782","","2023-08-01","8/1/2023 Rcvd email from Kathy Torres at MQA that provider is PAR with BCBS TX effective 6/29/2023.  PID # 1609921782.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete",45078,"","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete",45078,"","","2023-08-23","08.23.2023 S/W Bridgette of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 3694262. Physical location is on file. Call ref#:734006. - Danico Gabriel Melendres"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete",45202,"","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-09-19","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Add Info Submitted","2023-11-01","","","2024-11-15","Resubmitted request to add provider to all LOB's under SHP via Pact submisson. PA."]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","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","","Rail Road Medicare","Participating","Enrollment Complete",45194,"Q00593564","CE1588","2023-11-06","Received confirmation eff 9/25/2023. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","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"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete",45177,"","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2023-11-13","6C5573","","2023-11-03","Received welcome letter. MS"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","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"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Add Info Submitted",45177,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-11","","","2023-12-18","Welcome letter rcvd. Provider effective 12/11/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-07-10","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 7/10/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2024-05-20","5/20/2024- Spoke to DJ A. call ref# 6192837355, 616 N Main st location participating as of 7/10/2023. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-07","","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave, 210 West Longview Ave Ste A Bldg A and 6950 Eastridge  are effective 09/01/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-30","","","2024-04-25","4/25/2024 provider enrolled as of 6/30/2023 via roster. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-07-10","3701694","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/10/2023.  PID #3701694.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-07-10","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-07-10","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45163,"","","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"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-07-10","","","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"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45154,"","","2023-08-23","Provider is linked with Briarwood and Longview locations effective 8/16. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Revalidation completed. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Revalidation completed. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-08","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n616 N Main St.  & 6950 Eastridge Rd. Eff. 7/10/2023\n4705 Briarwood Ave eff. 10/8/2024. AS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-01-17","Per providerrelations@primehealthservices.comYour request has been received and being processed accordingly. However, at this time, I have no updates as to when the directory will be updated with the location add. \nPlease note, all Physicians/locations billing under the TIN you provided are subject to the terms of the PPO agreement and considered in network upon billing with the TIN.  Contract effective date 05/23/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Taylor Brown. Effective 12/05/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45117,"8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45160,"008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",45214,"","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-08-22","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-08-22","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-08-22"," 8574198","","2023-10-19","10.16.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 08/22/2023. Provider ID 8574198. Service location is on file. Call ref#:6166954339.-Danico Gabriel Melendres"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-09-29","","","2024-02-28","Re-Cred has been completed. eff 9/23/23. MS"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["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","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2023-09-27","Rcvd approval letter from Barry Harris at barry.harris@pswca.org. Provider effective 09/22/2023. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Add Info Submitted",45177,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45442,"","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-12-21","12/21/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/8/2023. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/8/2023. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with welcome letter from Karina Garcia effective 12/15/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/8/2023. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45442,"","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45177,"3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45177,"","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-09-08","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45177,"","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45177,"","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2023-09-27","Rcvd welcome letter from Barry Harris at barry.harris@pswca.org. Provider effective 09/22/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-20","WTUC has an active Ancillary Contract in effect, which means any midlevel will not require credentialing and all services will be billed under the group contract. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45474,"","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted",45208,"","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","","First Health Coventry","Participating","Add Info Submitted",45184,"2538236","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-10-09","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 10/9/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-10-09","","","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 10/9/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2023-10-04","","","2023-10-27","Confirmed provider is linked eff 10/4/2023. MS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2023-11-06","003305120","","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 # 003305120.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-12-01","1083394977","","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"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-08-14","Q00595265","CF8499","2023-11-07","See other payor line for enrollment notes."]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","2023-10-30","","","2024-09-18","19 st location"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2024-02-15","","","2024-09-18","19 st location: Received email from TriWEst Healthcare this provider is loaded and active eff 2/15/2024. MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete",45177,"1083394977","","2023-12-22","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 9/8/2023.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",45238,"","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/8/2023. \nMPIN # 004473172.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted",45238,"","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete",45238,"","","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 11/8/2023.  DCannon"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff.  11/06/2023 and linked to TIN. PA"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-04","Pending Aetna  Approval. MS"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",45236,"","","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 # 006259813.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","","Aetna","Participating","Add Info Submitted","2023-12-04","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete",45264,"","","2024-07-31","7/31/2024 As per Jessica Bess from Multipla, provider particpating as of 12/4/2023 received via email. FC"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete",45308,"","","2024-01-08","1/8/2024 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 1/17/2024.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and locations effective 11/06/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-10-27","Provider linked to Rosalind and Andrews Hwy location eff 9/28/2023. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45236,"006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",45236,"","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","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","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45200,"Q00656144","","2024-07-01","Main St. location approved 6/10/24. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45200,"Q00656144","","2024-02-05","Confirmed provider is enrolled eff 10/1/2023. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome ltr rcvd. Provider effective 12/15/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45275,"","","2024-01-05","Welcome ltr rcvd. Provider effective 12/15/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45189,"","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - 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","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted",45261,"","","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","No Value Specified","2023-12-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 12/01/2023, and linked to locations.PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45474,"","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-09","Payor has closed the panel for new providers. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45236,"","","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","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45236,"00390311","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390311.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete",45236,"","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45236,"008766524","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 008766524.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete",45261,"","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 12/01/2023, and linked to 616 Main St. location. PA."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - 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"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45334,"","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd eff. 11/6/2023\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"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45343,"","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45273,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45273,"","","2024-01-02","Provider is linked to this location effective 12/13/23. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",45327,"","","2024-07-04","7/4/2024 provider participating as of 2/5/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45200,"Q00615975","","2023-12-07","Received approval letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45236,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45200,"2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003261515.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/19/2024 Pending Multiplan enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is loaded to the Eastridge location eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45225,"","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2023-12-01","","","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."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390310977","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390310977.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390310977","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390310977.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome letter rcvd. Provider effective 12/15/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-12-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 12/01/2023 and linked to all locations. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 11/6/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 11/6/2023. AS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","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"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45224,"","","2023-10-24","Received confirmation provider is enrolled and participating with the following networks, eff. 10/25/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\n- PA"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Rcvd welcome letter. Provider effective 02/12/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-01","6C9153","","2023-11-08","Received welcome letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","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"]
["Alma Martinez, APRN-FNP-BC",1376149153,"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"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Alliance WC approval letter rcvd. Provider effective 01/19/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-04","","","2024-03-26","Sent email to Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/13/24 and 03/25/24 inquiring on location status. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently listed. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","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"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - 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","PE - 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","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-12-04","","","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"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45334,"","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-04","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - 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","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - 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","PE - 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","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-28","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45310,"","","2024-01-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45231,"","","2024-07-29","Received product roster. Provider is par and linked to TIN/location, eff. 11/01/2023."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"15380393","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","","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","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","","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","PE - 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","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",45323,"6K7369","0008AH","2024-02-27","Received welcome letter. MS"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","","Superior","Participating","Add Info Submitted","2024-02-01","","","2024-11-15","Resumitted request to add provider to all LOBs under SHP via Pact submission. PA."]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-07-02","","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - 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","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",45323,"Q00658762","CE1588","2024-02-07","Received approval letter. MS"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","","","","2024-01-09",""]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","","CAQH","In House Enrollment","In House Enrollment","","","","2024-01-09",""]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",45323,"","","2024-07-02","Received email confirmation from LaNetrice Myart provider is PAR, and linked to TIN/Location,  eff. 02/01/2024.  PA"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-02-05","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024  provider is PAR, eff. 02/05/2024. Location on file: 5615 Deauville BLVD, Suite 220. PA"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-07-04","7/4/2024 provider participating as of 2/5/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2024-03-01","","","2024-08-06","8/6/2024 Spoke to Paul R. call ref# 17821445, provider participating as of 3/1/2024. FC"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","",""]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","PE - 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"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2024-10-10","","","2024-10-15","Per Humana rep, Lea O, at 1-800-448-6262, ref# 2000412084823, provider is enrolled and linked to TIN/location, eff. 10/10/2024. PA."]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-03","8313945","","2024-06-18","S/W Claire of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 06/03/2024. No next recredentialing date provided. PIN: 8313945. Servicing location is on file. Payer# 60054. Call ref# 6194640428."]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete",45509,"","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Application Submitted","","","","2024-09-13","Submitted application via delegated roster on 9/13/2024. PA."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-07-01","6Q7671","","2024-05-20","Received enrollment confirmation. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2024-07-01","6Q7671","","2024-05-20","Received enrollment confirmation. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-09-09","","","2024-10-04","Received email confirmation Sept roster is processed. Provider is participating, linked to TIN and location, effective 9/9/2024. PA."]
["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","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested",45617,"","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",45474,"Q00774557","CE1588","2024-07-01","Provider has been approved and linked. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","First Health Coventry","In Process","Payor Follow Up","","","","2024-07-23","Provider not yet loaded into system. Still processing. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45413,"1184490161","","2024-05-09","Approval ltr rcvd. Effective 05/01/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-03-07","","","2024-04-15","4/15/2024- received email confirmation provider is par, eff.  04/16/2024, and participating with the following networks: PMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHMO - Blue Essentials\nHME - Health Select. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","2024-03-07","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","2024-03-07","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","2024-03-07","","","2024-06-21","Sent email to UHC requesting group roster. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45357,"","","2024-03-25","Received approval. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45387,"","","2024-07-31","Received email confirmation provider is par and linked to TIN/location, eff. 04/05/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-03-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024. AS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024. AS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45362,"","","2024-07-23","As per Kim Patterson from Caprock, provider participating as of 3/11/2024 via email. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 4/5/2024. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-04-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-04-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-04-05","","","2024-05-29","Provider participating as of 4/5/2024 received via email from Kodi Kox. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-05","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/05/2024. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-05","","","2024-05-09","Received confirmation from HPDelegation provider is PAR & locations linked, eff. 05/05/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-05","","","2024-05-09","Received confirmation from HPDelegation provider is PAR & locations linked, eff. 05/05/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","","","2024-04-22","Approval ltr rcvd. Provider effective 04/12/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - 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","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-04-05","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 4/5/2024. AS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-03-01","","","2024-07-31","Received email confirmation provider is par and linked to location, eff. 3/01/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45457,"1184490161","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-07","This TIN is not Tricare Credentialed, and the panel is closed to incoming requests. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",45383,"","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 4/1/2024. FC"]
["Robert John Cornell, MD",1457331803,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2024-04-01","0224388","","2024-04-24","Received confirmation email. MS"]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","In House Enrollment","In House Enrollment","","","","2024-04-16","Practice confirmed the office will enroll the provider. MS"]
["Robert John Cornell, MD",1457331803,"26-3789190","TX","PE - Permian Physician Services","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","BCBSTX","Participating","Enrollment Complete","2024-07-12","8WL530","","2024-07-11","Received email confirmation provider is PAR and linked to TIN/location, eff. 7/12/2024. Provider is participating with the following products: BAV - Blue Advantage HMO\nHMO - Blue Essentials\nBCA - BlueChoice PPO\nHME - Health Select\nMCH - Medicare Advantage HMO\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO\nSNP - Dual Eligible Special Needs Plan. PA."]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","IMS","Participating","Enrollment Complete",45453,"","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","Ambetter","Participating","Enrollment Complete",45566,"","","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","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-26","Received confirmation from payor via email stating roster is complete; provider is PAR and  linked to the TIN/location, effective 7/11/2024. PA."]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor request status. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45422,"1548026099","","2024-05-17","Welcome ltr rcvd. Effective 05/10/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45412,"","","2024-04-30","Received email confirmation provider is PAR, eff. 04/30/2024, participating in the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-04-30","","","2024-04-30","Received email confirmation provider is PAR, eff. 04/30/2024, participating in the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45054,"","","2024-04-11","Per updates@primehealthservices.com, our systems have been updated with request to add Stacy Hernandez NPI 1548026099. Effective date is contract date of 05/08/2023. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1548026099","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45444,"1548026099","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","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","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-14","1548026099","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-01","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6950 Eastridge Rd,  6301 Andrews Hwy 10/4/2024.\n616 N Main St, 4705 Briarwood Ave 5/6/2024\nAS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-10","WesTex Urgent Care PLLC  is currently contracted with Cigna via an Ancillary contract. This provider does not require credentialing or contracting and should bill all services rendered under the Ancillary contract."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 06/06/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - 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."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-07-01","All locations are enrolled under the group record. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-04-08","","","2024-04-09","Location is not Tricare Credentialed, and the panel is closed for new providers. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-04-08","","","2024-04-09","Location is not Tricare Credentialed, and the panel is closed for new providers. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-05-06","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 05/06/2024. PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-04-22","","","2024-04-24","Received email confirmation provider is PAR, eff. 04/22/2024, participating with the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1093796435","","2024-05-06","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-12","Locations are not Tricare Credentialed and they are not accepting new providers. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-12","Locations are not Tricare Credentialed and they are not accepting new providers. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-04-12","","","2024-04-28","Provider is linked to all 5 locations eff 4/12/24. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/26/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/26/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-12","Group holds an ancillary contract where services are billed through the group, not the individual. Credentialing is not required. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","8016068","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45418,"8016068","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 5/6/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-05-06","","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-05-06","","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45495,"","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-04-24","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45569,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main St., 6301 Andrews Hwy, 6950 Eastridge Rd., 4705 Briarwood Ave eff. 10/4/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-13","Q00738696","DX4335","2024-05-14","Received approval. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-13","Q00738696","DX4335","2024-05-14","Received approval. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Welcome ltr rcvd. Effective 05/10/2024. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00744975","DX4335","2024-05-22","Received confirmation. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-06-10","","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff.  06/10/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-05-15","","","2024-05-15","Received email confirmation provider is PAR, eff. 05/15/2024, TIN and all locations linked, participating with the following networks: BCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","","","2024-05-08","Received enrollment confirmation. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/11/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/11/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45453,"","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Application Resubmitted","","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-07-24","Providers name has been updated and is linked to Briarwood location. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-11-26","Provider is linked to Andrews Hwy and Main St. locations. mS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-18","Received response and they are escalating the issue. Ticket #25624. Please allow 4-10 business days for update. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10//2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Approval ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Approval ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-04-28","Facility Contract - No individual enrollment required as all billed services are done through the group, not the individual. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n6950 Eastridge Rd, 616 N Main St, 6301 Andrews Hwy, 4705 Briarwood Ave eff. 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n6950 Eastridge Rd, 616 N Main St, 6301 Andrews Hwy, 4705 Briarwood Ave eff. 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-04-28","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45408,"","","2024-08-09","Welcome ltr rcvd. Effective 08/01/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-28","Panel is closed to new providers. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-06-10","6324539","","2024-10-29","Received confirmation via deleagted roster from Brandy Smith Provider participating effective06/10/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Please see status updates under Alliance WC payor line. Jen Videan"]
["Rizwan Asim, MD",1205287646,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","In Process","Application Submitted","","","","2024-12-02","Your application has been submitted and is now under review. Your request number is: 20609009. Jen Videan"]
["Rizwan Asim, MD",1205287646,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2024-09-01","7B5597","519061","2024-11-19","Provider Approved. MS"]
["Kwame B Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2024-09-09","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective  9/9/2024. PA"]
["Kwame B Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Hamza Muhammad Tola, MD",1154818342,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete",45597,"","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Hamza Muhammad Tola, MD",1154818342,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2024-10-31","","","2024-10-31","10/31/2024 CAQH sweep completed pklika"]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Pierre M Agnant, MD",1669868568,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Ugochukwu Ikechi Maduforo, MD",1447630033,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Ugochukwu Ikechi Maduforo, MD",1447630033,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2024-10-31","Pending Medicare enrollment, in process. Jen Videan"]
["Sahil Batta, MD",1801324306,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Sahil Batta, MD",1801324306,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete",45597,"","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Sheriffdeen O Ilo, DO",1184910382,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","In Process","Application Submitted","","","","2024-11-26","Application submitted to Medical Onboarding. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 Profile attested"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-07-24","Provider linked to all locations. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-07-24","Provider linked to all locations. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-08-28","","","2024-09-19","Received email confirmation provider has been added to Network, under TIN/locations, eff. 8/28/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted",45532,"","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-12-05","No credentialing required. Provider will bill under anxillary contract. mS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-05-21","","","2024-08-09","Welcome ltr rcvd. Effective 08/01/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-22","Group holds a facility contract. Midlevels will bill services under the group info, not individually. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-21","","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774238","DX4335","2024-07-01","Provider has been linked to group. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","","","2024-10-01","Approval ltrd rcvd. Effective 08/16/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-18","Submitted via delegated roster on 7/15/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-18","Submitted via delegated roster on 7/15/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-21","","","2024-10-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n616 N Main st eff. 8/1/2023\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 8/1/2023. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-05-22","WTUC is not Tricare Credentialed and the network is not accepting new providers. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Medicare","","","","2024-11-26","Group application to add this location was submitted. Once approved, the provider will be linked to this location. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45447,"1366816829","","2024-06-11","Welcome ltr rcvd. Provider effective 06/04/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-22","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2024-11-18","","","2024-11-18","11/18/2024 CAQH Sweep completed pklika"]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","Provider Load","DO NOT ENROLL","2024-06-14","","","2024-06-14",""]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - 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","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - 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","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-17","None of the 3 locations are Tricare credentialed, and since the panel is closed to new enrollments there is nothing else needed at this time. MS"]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2024-08-05","1598517369","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2024-05-28","","","2024-09-03","Received confirmation. MS"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-11-19","Received confirmation of Triwest. I've reached back out to the provider for an effective date. MS"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2024-08-05","9242351","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Medicaid","In Process","Pending Info/Document","","","","2024-11-13","Requested confirmation of Audrey's taxonomy code. The intake form we received for her has 363LF0000X, whereas NPPES and TMHP has 363L00000X. Jen Videan"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-27","Panel is closed to new providers. Nothing else is needed at this time. MS"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2024-08-05","","","2024-10-29","Received notification via email, provider participating as of 8/5/2024. FC"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Aetna","Participating","Enrollment Complete","2024-08-01","","","2024-10-08","Received confirmation via email from Aetna, provider participating eff date 8/1/2024. FC"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","1598517369","","2024-09-04","Roster and email confirmation received from the payor. Payor confirmed provider is PAR, eff. 9/5/2024, linked to the TIN and locations. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-09-20","Received notification via email from Jessica Bess, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Thru Other Payor","","","","2024-12-03","Boon-Chapman serves as a third-party administrator for Aetna and is accessible via the Aetna network. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2024-10-10","","","2024-10-17","Per Humana rep, Ivy G, at 1-800-448-6262 (ref# 2000412747506 ), provider is participating, linked to TIN and both locations, eff. 10/10/2024. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-07-22","Received welcome letter. MS"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2024-08-01","","","","Received confirmation via email from Aetna, provider participating eff date 8/1/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from German Aviles, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-07-01","4357405","","2024-07-30","Received confirmation of enrollment. MS"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2024-10-08","Received confirmation via email from FirstHealth provider participating eff date 8/1/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","1144933367","","2024-09-04","Roster and email confirmation received from the payor. Payor confirmed provider is PAR, eff. 9/5/2024, linked to the TIN and locations. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2024-11-08","Received email confirmation from LaNetrice M,  provider is par and linked to TIN & locations, eff. 8/15/2024. PA ."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","","Medicaid","In Process","Action Needed","","","","2024-11-14","Provider is enrolled with MCR eff 12/23/2004. MR"]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","","Multiplan","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Amanda L Marshall, MD",1518195346,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","In Process","Action Needed","","","","2024-12-04","Medicare was approved. Please enroll with MCD. MS"]
["George J Germanos, MD",1144858390,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["George J Germanos, MD",1144858390,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete",45614,"7B5598","519061","2024-11-19","Provider Approved. MS"]
["Aliaksandr Savitski, MD",1053654863,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Aliaksandr Savitski, MD",1053654863,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Samantha A Hall, DPM",1942592803,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-11-15","Application submitted online. Request ID 25805447 MS"]
["Aimel Azizi, MD",1144480997,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Aimel Azizi, MD",1144480997,"47-5554737","TX","PE - Midland Inpatient Medical Association","PPHP","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster."]
["Aimel Azizi, MD",1144480997,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-11-01","Q00897593","DX4335","2024-11-27",""]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-10-16","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-10-16","TSCA and required documents emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-10-04","","","2024-10-16","Application submitted via pswca.org. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-10-16","Please see status update under Alliance WC payor line. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-11-25","","","2024-11-22","Received welcome letter. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In Process","Application Submitted","","","","2024-11-18","Submitted application via email to Scarlett A. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2024-11-26","Enrollment complete for all 5 original location. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Application Submitted","2024-10-16","","","2024-11-26","Application submitted to add to Big Spring location. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-10-16","This group has an active ancillary contract. No midlevels will need to be credentialed and all services are billed through the group. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster.Pending UHC enrollment. PA"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-10-16","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-18","Per updates@primehealthservices.com provider has been loaded. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45582,"","","2024-10-16","Received welcome letter from BCBSTX via email. Provider is participating, eff. 10/17/2024, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO. PA."]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. Pending Superior enrollment. PA."]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Provider Load","Provider Load","","","","2024-10-21",""]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In Process","Pending Info/Document","2024-11-01","","","2024-11-01","11/01/2024 Cannot Re-attest Missing CAQH UN/PW"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In Process","Pending Info/Document","2024-11-01","","","2024-11-01","11/01/2024 Cannot Re-attest Missing CAQH UN/PW"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. Pending Superior enrollment. PA."]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster.Pending UHC enrollment. PA"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",45617,"9443693","","2024-12-05","Received confirmation email. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-02","Panel is closed. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-02","Panel is closed. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-15","This location is not Tricare certified, and the panel is closed to new enrollments. mS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-26","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2024-11-15","Application submitted via email .MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2024-11-15","Application submitted via email .MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-15","See group payor line. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-11-15","Pending Medicare approval. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-12-02","Emailed TSCA and required documents to . wwtxcontracts@texasmutual.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2024-11-27","Surrogacy is required, and the provider has not yet approved. Client notified. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-11-26","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-11-26","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-11-18","","","2024-11-26","All 5 original location are confirmed. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-11-18","","","2024-11-26","All 5 original location are confirmed. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2024-11-26","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-12-02","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-11-25","","","2024-11-26","Received email confirming provider is PAR and linked to TIN and location, eff. 11/25/2024, participating in the following LOB's: HMO - Blue Essentials\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nPMC - Medicare Advantage PPO. PA."]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-11-25","","","2024-11-26","Received email confirming provider is PAR and linked to TIN and location, eff. 11/25/2024, participating in the following LOB's: HMO - Blue Essentials\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nPMC - Medicare Advantage PPO. PA."]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-27","","","2024-11-27","11/27/2024 CAQH Sweep completed pklika"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Amerigroup","Participating","Re-Credentialing","2019-07-30","1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James H Barnett, MD",1356484497,"27-4061759","TX","","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."]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Humana","Participating","Enrollment Complete","2010-10-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/1/2010.  DCannon"]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","HealthSmart PPO","Participating","Add Info Submitted","2012-01-01","1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","IMS","Participating","Enrollment Complete","2001-09-01","1124009766","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Cigna","Participating","Enrollment Complete","2012-01-24","1124009766","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 1/24/2012. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Re-Credentialing","2021-12-06","10122396","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Amerigroup","Participating","Re-Credentialing","2022-04-14","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","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","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","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","","IMS","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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed. eff 1/2/2024. MS"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Michael J Dragun, MD",1679574099,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-10-01","Q00884264","","2024-11-12","Provider is approved. MS"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1091200","","2020-03-24","3/24/2020-received email with roster stating provider PAR 9/1/2008 PID # 1091200\ntisha rader"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicaid","Participating","In House Enrollment","","080363701","Unknown","2020-10-23","10/23/2020 - Rec'd email from the clinic stating \"I spoke with Swapna Patel, the office manager for Dr. Mrunal and Dr. Govind Patel. \nYes, they participate in Medicaid but they will be taking care of it themselves.\n\nTheir TPI # is 0803637-01.\n\nShe doesn’t know the effective date because they’ve had it so long.\"  - Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","1999-04-01","1659366433","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2014-09-29","1659366433","","2020-03-25","3/25/2020--S/W Mary of Aetna @ 8003531232,  provider NPI# is on file for the provider and is participating effective 09/29/2014 under the group and TIN#. Physical location is on file. DIRECT CONTRACT --Call ref#: 5194781237. \nTISHA RADER"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","1103233","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/1/2021.  PID #1103233  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2021-08-01","1103233","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-26","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","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","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff. 3/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Lawrence Wilson, MD NPI: 1518951342- credentialing approved since 01/19/2022, renewal 01/19/2025. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Multiplan","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45047,"","","2023-09-02",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome letter rcvd. Provider eff 12/01/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 9800227 DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",44403,"","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44421,"","","2022-02-07","2/7/2022 Rcvd roster from Multi plan listing provider as PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - 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","","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","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-26","Q00177598","DX4335","2021-12-08","12/8/2021 Rcvd RR Medicare PTAN Approval letter instantly.  RR Medicare PTAN#  Q00177598 - effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood and 6950 Eastridge is effective 08/01/2022. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-06-01","","","2024-07-02","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 06/01/2023. PA"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - 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","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45281,"","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted",45047,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/26/2021. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-08-11","","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Wellmed","Participating","Enrollment Complete","2021-08-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/24/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-16","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 11/16/2021. PA"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","","","","2024-07-31","Approval ltr rcvd. Effective 04/05/2024. Jen Videan"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Multiplan","Participating","Enrollment Complete","2023-12-11","","","2024-06-04","6/3/2024 Spoke to Dominique call ref#10413020, location has been added to TIN as of 12/11/2023. FC"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2013-09-01","1907709","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 1907709 - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Re-Credentialing",43664,"1942216122","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2012-10-01","1942216122","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","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","PE - Permian Gastroenterology PA","Caprock (CapStar)","Participating","Application Resubmitted","2012-03-01","1073555249","","","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD",1073555249,"74-2348334","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"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Multiplan","Participating","Enrollment Complete","1996-10-01","1073555249","","2020-02-12","02/12/2020 - rec'd confirmation through payer portal that this provider is EFF through and INDIVIDUAL CONTRACT as of 10-1-1996. Provider is in network with multiplan - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","Superior","Participating","Enrollment Complete","2020-08-01","1073555249","","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"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","Aetna","Participating","Enrollment Complete","2005-11-15","","","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"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-04-01","","","2023-06-21","Received COI application confirmation. Reference # 3231460484  MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2023-06-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2023-06-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-06-01","","","2023-10-27","10/27/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2013-08-01","P01348965","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer site - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2007-11-01","P00663946","DO2096","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1811900657","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Boon Chapman","Participating","Enrollment Complete","2008-12-10","12705210","","2022-02-24","2/224/2022 - Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 12/10/2008 under the group and TIN#. Provider ID#  12705210. Physical location is on file. Call ref# 7919804 -Marielle Pacheco"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-16","10/16/2023 Provider is not enrolled in Multiplan, therefore, provider is not enrolled in Boon Chapman.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295724698","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2013-04-08","","","2024-04-29","Re-Cred has been approved eff 4/5/2013. MS"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-01","1295724698","","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"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2011-02-01","1295724698","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295724698","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","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.\""]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-10-29","1912100850","","2023-08-24","8/24/2023 Per email received from IMS/Omni provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-10-29","1922008234","","2023-08-24","8/24/2023 Per email received from IMS/Omni provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff 10/4/2024\n6301 Andrews Hwy eff 5/6/2024\n6950 Eastridge Ave & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","318466ZP5M","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/9/2015.  PID # 318466ZP5M.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","00002067277","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 1/1/2020.   MPIN# 00002067277.   DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","","First Health Coventry","Participating","Enrollment Complete","2015-09-01","2230880","","2023-09-22","09.22.2023 S/W Bridgett of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2015. Provider ID 2230880. Service location is on file. Call ref#:764027. - Danico Gabriel Melendres"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-09-18","","","2024-11-12","11/12/2024 Invalid CAQH PW pklika"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024.."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","",45604,"Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider linked to Andrews Hwy location eff 10.26.2023"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","","",45338,"Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete","2004-10-01","1578557468","","2024-10-01","Provider is showing 207Q00000X at both locations. Jen Videan"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2023-05-04","5/4/2023 Per email from UHC delegated roster from February has been processed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","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","PE - 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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","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","PE - 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","PE - 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","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2022-10-10","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Omni PPO","Participating","Re-Credentialing",40909,"1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Galaxy Health","Participating","Enrollment Complete","1999-04-28","1346236924","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/28/1999. - Jesriel Segovia"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","1730181389","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Caprock (CapStar)","Participating","Enrollment Complete",43709,"1730181389","","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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete",43709,"1730181389","","2020-08-21",""]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","9/15/2021 Per non network portal, provider is certified under this location. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2021-01-26","547155","","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"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete",44774,"","","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,"75-1997880","TX","","Wellcare","Participating","Enrollment Complete",44501,"","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Participating","Enrollment Complete","","","","2024-01-27","Confirmed provider is enrolled via the Integrated Network. MS"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Liberty Mutual","Participating","Enrollment Complete",37663,"1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Liberty Mutual","Participating","Enrollment Complete",37575,"1316965403","562697415","2020-08-21","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Multiplan","Participating","Enrollment Complete","1999-09-23","1316965403","","2020-02-12","02/12/2020 - Rec'd cofnirmation through payer portal that this provider is EFF 9-23-1999 under an INDIVIDUAL CONTRACT. Provider is networked with Multiplan - Stacey  Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1316965403","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","","Omni PPO","Participating","Enrollment Complete",36906,"1316965403","","2020-06-25",""]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",45591,"","","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","PE - C Vallie CFNP Limited Partnership","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete","2021-02-08","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","IMS","Participating","Re-Credentialing","2014-10-31","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-04","10697754","","2020-07-21","07/21/2020 - Rec'd email with a spreadsheet from the payer indiciating this provider is EFF at this service location with this TIN - linked to WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1780892760","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Wellcare","Participating","Enrollment Complete",44501,"","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Humana","Participating","Enrollment Complete",43586,"1780892760","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Humana","Participating","Enrollment Complete",43586,"1780892760","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Triwest VA","Participating","Enrollment Complete",44331,"","","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"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","","IMS","Participating","Enrollment Complete",45316,"","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 1/25/2024. AS"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Medicaid","Participating","Enrollment Complete",43586,"296523803","397597101","2020-05-01","05/01/2020 - Rec'd confirmation of this information from the providers staff - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Superior","Participating","Enrollment Complete","2020-10-01","1780892760","","2020-10-01","10/01/2020 - rec'd email from the payer stating this provider has been updated and made EFF off the roster - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","","Amerigroup","Participating","Enrollment Complete",45548,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 9/13/2024. AS"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","United Health Care","Participating","Enrollment Complete",43586,"3334870","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested",45622,"","","2024-11-26","11/26/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete",45536,"","","2024-09-27","Received email confirmation provider is par and linked to TIN/location, eff. 9/1/2024.  PA"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",45509,"","","2024-10-29","Received notification via email, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-09-04","Pending MCR approval. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete",45509,"","","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","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45566,"0323199","","2024-10-18","Received confirmation email. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-13","Pending location add to group record. In process. Jen Videan"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",44075,"4341928","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers service location/TIN update has been completed - \"Name: Chandan Mazumber\nPID: 4341928\nEffective date: 09/01/2020\" - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",44075,"1093928913","","2020-10-08","10/8/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-09-01","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Add Info Submitted","2012-10-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/12/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","","Omni PPO","Participating","Add Info Submitted","2020-08-01","","","2024-09-13",""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2012-12-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2022-06-01","6/1/2022 Rcvd email from German Aviles at IMS/OMNI that delegation roster for April have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2023-05-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Add Info Submitted","2023-05-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2023-05-01"," 2868832","","2023-10-19","10.17.2023 S/W Bridgette of First Health @ 800-226-5116. Per rep, provider is showing as participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 2868832. Service location is on file. Call ref#:788770.-Danico Gabriel Melendres"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-09-17","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9132703  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","293166YM2M","00304W","2020-09-22","9/22/2020 - created this payer line to house effective information - this is not maintained by Symplr. This is maintained by IN HOUSE by the clinic\n\nRec'd confirmation from the clinic that this service location has been approved under the group enrollment - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2013-09-01","","","2020-09-14",""]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicare enrollment is done in-house by MCHS.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2013-08-01","1336304120","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2024-11-06","","","2024-11-06","11/06/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Omni PPO","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","First Health Coventry","Participating","Enrollment Complete","2023-01-09","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group/location effective 1/9/2023.  PID # 1961903.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Galaxy Health","Participating","Enrollment Complete","2023-01-09","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 1/9/2023.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology 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."]
["Leela K Lella, MD",1306162557,"27-4061759","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306162557","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal stating : Provider:Leela Lella\nNetwork: MPI\nNetwork Participation effective:6/19/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-03-18","07416220","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete",43740,"10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1528299872","","2020-10-05","Enrollment thru PHCS"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","","Aetna","Participating","Enrollment Complete","","","","2024-11-20","Provider is linked to this location per the directory. MS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-03-18","","","2023-08-31","8/31/2023 Per Amerigroup portal provider has been added to new location.  Provider effective date 3/18/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","","IMS","Participating","Enrollment Complete","2023-04-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 4/1/2023. AS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1528299872","","2020-07-27","07/27/2020 - Rec'd information back from the payer stating this provider/service location was added off of the July 2020 roster - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","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 AK Ansari, MD",1528299872,"26-3789190","TX","","Caprock (CapStar)","In Process","Application Submitted","","","","2024-09-13","Submitted application via delegated roster. FC"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete",45139,"","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Audrey N Mangwiro, MD",1346265162,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-24","","","2021-02-11","2/11/2021 Received email of provider approval from BSWHPEXPEDITES@BSWHealth.org with an effective date of 2/24/2021 and asks to allow 3-4 weeks before submitting claims so they may complete the configuration of provider load in their system. KFrazier"]
["Alaaedin Alhomosh, MD",1063709913,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Pending Other Enrollment","Pending Medicare","2024-11-09","","","2024-12-03","Pending Medicare enrollment, in process. Jen Videan"]
["Alaaedin Alhomosh, MD",1063709913,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-26","Pending Aenta approval. MS"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-27","366768ZV0W","519061","2020-12-31","12/31/2020 Confirmed via PECOS provider is currently assigned PTAN 366768ZV0W under group effective 11/27/2016. KFrazier"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster 10/15/2024. FC"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","In Process","Application Submitted","","","","2024-10-28","Submitted application via delegated roster on 10/15/2024. PA."]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster 10/15/2024. FC"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","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."]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-11-22","13683951","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2017-08-30","1295109510","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-13","Ste. 200 is not a Prime Credentialed location. Panel is closed. MS"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2016-12-14","1215254156","","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 12-14-2016 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2016-10-01","1598757080","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10/1/2016  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2016-10-26","1215254156","463131679","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26","1467745240","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-08-30","1467745240","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-05-12","1467745240","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-01","","","2024-02-28","Re-Cred has been completed. eff 1/1/2020. MS"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Application Resubmitted","2023-02-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Application Resubmitted","2023-02-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-10-26","1770883191","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","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."]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2015-12-01","1770883191","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-11-22","12284010","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","CAQH","Active","CAQH Reattested","2024-11-22","12284010","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2020-01-29","01/29/2020 - moved to completed status after confirming provider is linked in payer portal. Provider is participating with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-13","1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- ---roster also shows effective date: 1/1/20--Tisha Rader"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/24/2018.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 02/01/2011.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1099473","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1099473\n-tisha rader"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","","","2020-09-02","09/02/2020 - Rec'd email confirmation that this service location has been added to the provider profile - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","TXB131681","00304W","2020-09-22","9/2/2020 - rec'd confirmation from the clinic that this service location has been added to the group enrollment.  - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-12-19","367241202","364596201","2021-04-12","4/12/2021 Upon review of group TMHP portal, provider has been approved effective 12/19/2020 with assigned TPI 367241202. KFrazier"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2021-05-01","","","2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","In Process","Pending Info/Document","2013-10-01","322577YN4B","","2024-11-27","Still pending surrogacy. Client notified. MS"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","2015-09-12","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-07","3218941","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/7/2021 with assigned provider ID 3218941. KFrazier"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","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."]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Humana","Participating","Enrollment Complete","2011-03-01","1134151756","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1134151756","","2020-04-16","04/16/2020 - Rec'd spreadsheet from payer indiciating this provider is EFF with PPPO & Medicare products under the PRIMED DELEGATED agreement under this TIN/Service location - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","United Health Care","Participating","Enrollment Complete","2015-10-26","1184727562","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1184727562","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with PPO only products with this TIN/Service Location- Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","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","PE - 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","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2019-09-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 9/1/2019. KFrazier"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-08-01","","","2023-10-10","Received confirmation of the locations being added. MS"]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","Humana","Participating","Payor Follow Up","2024-04-01","","","2024-07-18","Per Humana rep Jona P (1-800-448-6262, ref# 2000392187965), provider is par and linked to TIN, eff 04/01/2024. Location confirmation pending. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","","","2024-07-02","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 08/28/2015. PA"]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmation received  the provider is linked to Briarwood location effective 9/20/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/location, eff. 12/01/2018. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","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","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - 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","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-29","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-02-13","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 2/13/2024 for Main St location. FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2015-09-01","1906310","","2023-10-23","10.23.2023 S/W Trina of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2015. Provider ID 1906310. Service location is on file. Call ref#:773486.-Danico Gabriel Melendres"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2015-09-01","1906310","","2023-10-23","10.23.2023 S/W Trina of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2015. Provider ID 1906310. Service location is on file. Call ref#:773486.-Danico Gabriel Melendres"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-01","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 08/01/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - 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","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","this location has been linked to the group record and provider is listed under the group. Nothing further is needed. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","12235261","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2024-03-08","","","2024-07-31","7/31/2024 As per Jessica Bess from Multipla, provider particpating as of 3/8/2024 received via email. FC"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/15/2020.   DCannon"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1087929","","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"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","CAQH","Active","CAQH Reattested","2024-11-05","13752595","","2024-11-05","11/05/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","1760501720","752656723","2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","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 M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20","1760501720","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760501720","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2020-01-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2020-01-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2014-05-12","1760501720","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2015-04-29","01448885","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012; Medicare - eff 8/1/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","2020-10-02","10/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2009-02-12","1093937948","","2020-06-25",""]
["Nikolay A Azarov, MD",1093937948,"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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2015-04-29","1093937948","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1093937948","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - stacey hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 12/1/2014.  PID #2681483  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","9469407","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 10/1/2019.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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","","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2016-06-01","1376723361","47-3465832","2020-06-16","06/16/2020 - CIGNA has an ancillary contract in place for this WesTex Urgent Care (as an urgent care center) that's EFF 6-1-2016.\nPer payer, each provider does not need to be credentialed as long as the facility and service location is on file. I confirmed that all service locations are linked to group contract (1941 E 37th St, 210 W Longview Ave & 3401 Gerenbriar Ste 200) - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"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","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","2015-12-01","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1376723361","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1376723361","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","13780299","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","13780299","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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","","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-11-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 11/01/2017, and linked to 616 Main St. location. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Amerigroup","In Process","Add Info Submitted","","","","2024-07-22","Added provider to July roster via delegated roster again. FC"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","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","","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-03","Group holds am Ancillary contract which will bill for the midlevel services under the group. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not showing on the Coventry portal. Please add to next delegated roster submission. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Sedgwick","Participating","Enrollment Complete","2018-12-14","1214700","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2018.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","","","2020-09-14",""]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2017-02-01","190978001","079837301","2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","In Process","Application Submitted","","","","","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","615599ZP5M","","2020-06-15","06/15/2020 - Rec'd spreadsheet from the clinic stating this proivder is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"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","","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 12/1/2014 PID # 2681483\ntisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","United Health Care","Participating","Enrollment Complete","2024-02-01","003026419","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 003026419.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8867748 DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-06-25",""]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2011-05-04","1790972610","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2011-02-01","2271235","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 2/1/2011 PID # 2271235\ntisha rader"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2017-04-15","1225182314","","2020-10-05","Enrolled thru PHCS"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Omni PPO","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-25",""]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-08-01","","","2024-09-20","Received confirmation via phone call from Kodi Cox address participating as of 8/1/2023. FC"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2018-01-30","","","2024-09-05","Received confirmation from Krystal T. from WellPoint via telephone call provider address with suite 251 is effective as of 1/30/2018. FC"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc DUPE","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-29","","","2024-10-07","Received confirmation via email, provider participating effective 11/29/2017. FC"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","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","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-11-26","","","2024-11-26","11/26/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2024-03-20","60308","","2024-03-22","03.22.2024 WR: Called Cigna@ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to PaulaM. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 03/20/2024. Next recredentialing date is on 03/20/2027. PIN: 0998740. Servicing location is on file. Payer# 60308. Call ref# PaulaM03242024."]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-06-10","Received email confirmation provider's enrollment date has been backdated to 01/01/2024. PA."]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-08-01","1101456","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2011 PID # 1101456-tisha rader"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2009-12-07","147713503","079837301","2020-01-20","01/20/2020 - Logged into TMHP and verified this provider to be currently EFF and linked to: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Superior HealthPlan - MRSA West, Superior Health Plan - MRSA West under our group.  - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2009-12-07","147713503","079837301","2020-12-15","12/15/2020 Upon review of TMHP portal and per email forwarded from Candace Wynne, provider's revalidation is complete and will be due for revalidatio 12/13/2025. KFrazier"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1376556019","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-02-13","1376556019","","2024-02-29","Provider is linked to this location. MS"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing","2010-02-26","1558392779","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","187586602","079837301","2024-07-26","Approval ltr rcvd for 2402 W Wall St. Effective 05/29/2023. Jen Videan"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1174241","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-10-01","0186460","","2020-02-27","02/27/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed\" Completion Notice - Cigna Internal Reference # W20200226902641\nHCP Name: Rebecca Sanchez\nPID: 0186460\nEffective date: 10/01/2019  - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Terminated","Terminated","2021-08-01","002904472","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Terminated","Terminated","2022-01-01","1881711778","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2010-08-01","1945548","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2010 PID # 1945548-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","HealthSmart PPO","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2010-07-25","284181901","","2023-09-18",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1142937","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Add Info Submitted","2021-08-02","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Omni PPO","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-26",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1881711778","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","IMS","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Cigna","Participating","Enrollment Complete","2021-08-01","9097673","","2021-09-01","9/1/2021 Received an email from pdmcogz@cigna.com confirming additional location has been updated for group with an effective date of 8/1/2021, and assigned provider ID 9097673. KFrazier"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-02","1124350442","","2020-07-15","07/15/2020 - Rec'd welcome letter stating this provider is EFF 7-2-2020 with STAR, STAR+PLUS & Star Kids products - Stacey Hudak"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","CAQH","Participating","CAQH Reattested","2024-11-14","12067517","","2024-11-14","11/14/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - 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","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2012-07-01","1487837712","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 7-1-2012 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Aaron B Stike, MD",1366652315,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-10-01","6Y9795","0008AH","2024-10-08","Confirmed provider has been linked. MS"]
["Aaron B Stike, MD",1366652315,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-08-05","","","2024-08-30","Received email confirmation provider is PAR and linked to TIN/location, eff. 08/05/2024. PA."]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-11-15","","","2021-12-13","12/13/2021 Rcvd Multiplan approval letter.  Provider is PAR effective 11/15/2021.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-02","","","2022-03-09","3/9/2022 Per Tricare portal provider is certified and linked to location as of 3/2/2022. Cbankston"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01","4689558","","2022-08-10","8/10/2022 Per Aetna web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID# 4689558  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2021-11-18",""]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. Pending Superior enrollment. PA"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-03","553333ZV0W","519061","2024-11-19","Provider approved. MS"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster."]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-22","","","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","","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Aetna","Participating","Enrollment Complete","2024-05-22","","","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,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","Omni PPO","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","PE - Delight Pediatrics","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-10","","","2024-09-30","Received confirmation via email, provider participating as of 10/10/2022. FC"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-12-01","1013320050","","2023-01-11","1/11/2023 Rcvd TMHP portal provider is PAR and linked to group/ location effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","Cigna","Enrollment on Hold","Application Submitted","","","","2024-07-23","Application submitted via email to Medical Onboarding. MS"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-22","10/22/2021 Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Rail Road Medicare","Participating","Enrollment Complete","2021-04-28","P02630882","EB1950","2021-11-18","11/18/2021 Rcvd RR Medicare PTAN # P02630882 - eff 4/28/2021.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","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."]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1619008141","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","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"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","IMS","Participating","Enrollment Complete","2012-02-02","1093935975","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","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","PE - West Texas Ob/Gyn","Aetna","Participating","Application Resubmitted","2022-01-10","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Application Resubmitted","2022-01-10","12802966","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","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","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-07-27","P01732056","DW7662","2021-08-06","8/6/2021 RR Medicare PTAN received instantly via RR Medicare online portal.  PTAN # P01732056 - effective 7/27/2016.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","1871782961","","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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","Aetna","In Process","Payor Follow Up","","","","2024-10-17","As per Brandy provider not yet enrolled. Will resubmit in October roster. FC"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2024-09-09","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 9/9/2024. AS"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-09-16","414123ZV0W","519061","2024-08-20","Provider is active and linked to this group eff 9/16/2016. MS"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-12","Location is not Tricare credentialed, and the panel is closed to new enrollment. MS"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 9/9/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-17","","","2024-11-25","Per UHC rep Jeevanantham via online chat: \"The requested provider is having an active contract under the respective TIN with an effective date of 10/07/2024.\" PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-07","","","2024-08-30","Approval Ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-08-16","","","2024-09-19","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Enrollment Stopped","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd, Effective 09/18/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-10","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-10","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-08-06","","","2024-08-06","Approval ltr rcvd. Effective 08/06/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-12","1285175927","","2024-06-12","Per updates@primehealthservices.com,  Effective 06/12/2024, Henry Sirengo is now enrolled with Tax ID: 47-3465832. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-10-02","Provider is linked to the Eastridge location. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-10","Panel is closed to new enrollments. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-13","","","2024-09-12","Received email confirmation from BCBSTX, provider is par, eff. 6/13/2024, and linked to TIN/locations. Provider is participating in the following LOB's: •       Blue Choice PPO: 06/21/2024\n•       Blue Advantage HMO: 06/21/2024 \n•       Blue Essentials HMO: 06/21/2024 \n•       Health Select: 06/21/2024 \n•       Medicare Advantage PPO: 06/21/2024 \n•       TriWest T5 TriCare Program: 01/01/2025 . PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Application Submitted","","","","2024-07-15","Submitted application via delegated roster submission. PA."]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-02-01","1053601344","","2020-10-02","10/02/2020- moved to the completed status after reviewing follow up note - Stacey Hudak"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1053601344","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1053601344","","2020-06-26",""]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-04","1053601344","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-4-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2019-02-28","1972816189","","2020-06-29","06/29/2020 - confirmed IMS is par - therefore this enrollment is also effective - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2019-07-30","1972816189","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1972816189","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","","381744701","356723201","2024-01-01","Per TMHP, provider is enrolled and license has been updated. Jen Videan"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-01","0040519489","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 11/1/2023.  MPIN# 0040519489.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-09","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/9/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-01","","","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 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-11-01","Q00615984","","2023-12-07","Received enrollment confirmation. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","BCBSTX","Participating","Enrollment Complete","2024-01-03","","","2024-08-29","Received email confirmation provider is par and linked to TIN/location, eff. 1/03/2024. PA."]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","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","PE - Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1255614970","","2020-07-27","IMS complete"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1255614970","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","","Cigna","Participating","Enrollment Complete","2016-12-20","6703681","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1139406","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","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","","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-07-30","Received confirmation provider is PAR and linked to location, effective 1/1/2024. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 04/01/2022. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","HealthSmart PPO","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","PE - Permian Digestive Disease Center PA","Omni PPO","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","","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Medicare","Participating","Enrollment Complete","2016-01-09","363723ZS6M","472274","2020-05-04","05/04/2020 - confirmed provider is EFF thorugh PECOS for this provider - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","First Health Coventry","Participating","Application Resubmitted","2024-02-13","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Aetna","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","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Application Resubmitted","2016-05-01","1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 2/05/2024.  PA"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","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","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-02-06","","","2024-02-05","2/05/2024 - received an email confirmation provider is PAR, eff. 2/06/2024. Provider is PAR with the following networks: \nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO.  -PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-18","WTUC has an ancillary contract where midlevel services are billed under the group contract. Individual enrollment isn't required. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Payor Follow Up","","","","2024-07-29","Receivied email confirmation provider is linked to locations. Awaiting effective date confirmation. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","","","","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","","","","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-04-05","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 3/1/2024 with all 5 locations. FC"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-03-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2024-05-22","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-01","Q00681843","DX4335","2024-03-06","Provider is linked. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-17","Received email confirmation from Marina Martinez (marina.martinez@usamco.com) provider is PAR, eff. 02/05/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-01","6H8501","","2024-01-31","Received approval letter eff 2/1/2024. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-01","6H8501","","2024-01-31","Received approval letter eff 2/1/2024. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 all locations  participating as of 2/5/2024. FC"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/locations, eff. 03/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","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","","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","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","IMS complete"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - moved to the completed status after getting an email from the payer stating this demo update has been completed - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 2438435. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Add Info Submitted","","","","2024-12-04","Payor was requesting DEA again.. this was submitted back via fax. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Add Info Submitted","","","","2024-12-04","Payor was requesting DEA again.. this was submitted back via fax. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-09-30","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-11-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-09-30","Application and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-10-24","","","2024-11-26","Provider is linked to Briarwood location eff 10/24/24. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-10-24","","","2024-11-26","Provider is linked to Briarwood location eff 10/24/24. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","Application submitted to link to Big Spring location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2024-11-12","11/12/2024 location added, see other CAQH tab for exp dates pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Pending initial enrollment completion. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-12","Pending initial enrollment completion. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-09-30","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1265872592","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2016-09-22","1265872592","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/22/2016 under the group and TIN#. Provider is delegated to  PE - Midland Inpatient Medical Association. Physical location is on file. Call ref# 5309657469. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-20","1265872592","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-22","13885700","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-23","1265872592","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN/Service Location - Stacey Hudak\n\n**rec'd confirmation that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1265872592","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","363331502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-01-23","512648ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider EFF through PECOS group enrollment - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2016-12-15","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Provider Load","CAQH Reattested","2024-10-25","","","","10/25/2024 TX License uploaded to CAQH pklika"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2020-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2020-03-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-03","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing","2017-02-23","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-17","553519ZV0W","519061","2020-04-20","04/20/2020 - verified completed enrollment through group PECOS - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-04-03","1013456649","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-05-14","P01880121","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-05-14","579253ZV0W","519061","2020-04-20","04/20/2020 -confirmed provider is EFF through group enrollment in PECOS - Stacey Hduak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1013456649","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312317","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-01","1013456649","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-05-08","1013456649","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 05/08/2020 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-06","11/6/2020 Received email from United_Healthcare_Provider_Operations@uhc.com confirming provider is loaded under Group Tax ID and location for reference number PR-5512953 and assigned internal MPIN 006569937. Kimberly Frazier"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-07-22","As per January roster provider participating as of 8.1.2020 listed as a SPEC. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-06-01","1013456649","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1013456649","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service locatin and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2024-05-08","Rcvd approval ltr. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07","761311","0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","0669817","","2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31","1396930426","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01","","","2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","283737907","079837301","2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01","","","2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04","1396930426","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]

{"sheet":"TaxIDSearch","index":2,"n_rows":96,"n_cols":11,"rows_kept":96,"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"]
["Anusha Ammu, MD","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09",null,null,"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","PE - City of Midland Health Department","TriCare Standard","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-01","Enrollment is set up as an ambulatory enrollment and providers can not be added to it. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","USA PPO","In Process","Payor Follow Up",null,null,null,"2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete","2023-10-09",null,null,"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","PE - City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Wellmed","In Process","Payor Follow Up",null,null,null,"2024-07-08","Sent email to payor requesting status update. PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",null,"IMS","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","IMS","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"IMS","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Scott&White (First Care)","In Process","Payor Follow Up",null,null,null,"2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2024-02-06",null,null,"2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",null,"Multiplan","Participating","Enrollment Complete","2024-02-06",null,null,"2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Multiplan","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",null,"Omni PPO","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Omni PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06",null,null,"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","PE - City of Midland Health Department","Cigna","Participating","Enrollment Complete","2024-02-01",446524,null,"2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2024-02-06",null,null,"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","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"HealthSmart PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed",null,null,null,"2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Medicaid","Participating","Enrollment Complete","2024-09-03",null,null,"2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06",null,null,"2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Amerigroup","In Process","Add Info Submitted",null,null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2024-04-01",null,null,"2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",null,"First Health Coventry","Participating","Enrollment Complete","2024-04-01",null,null,"2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted","2024-04-01",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"First Health Coventry","Participating","Add Info Submitted","2024-04-01",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20",null,null,"2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20",null,null,"2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25",null,null,"2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD",null,"Aetna","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06",null,null,"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",null,"Aetna","Participating","Payor Follow Up","2024-02-06",null,null,"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","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up",null,null,null,"2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2021-03-01",null,null,"2021-08-24","8/24/2021 Received an email from united_healthcare_provider_operations@uhc.com with confirmation provider has been loaded under group Tax ID and location with effective date requested 3/1/2021. KFrazier"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"HealthSmart PPO","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2021-08-01",12731150,null,"2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 8/1/2021.  PID #  12731150.  DCannon"]
["Lawrence A Wilson, MD",null,"Amerigroup","Participating","Enrollment Complete","2021-08-01",12731150,null,"2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 8/1/2021.  PID #  12731150.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Amerigroup","Participating","Add Info Submitted","2021-08-01",12731150,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"Amerigroup","Participating","Add Info Submitted","2021-08-01",12731150,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","USA PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",null,"Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"Multiplan","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"Caprock (CapStar)","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Medicaid","In Process","Payor Follow Up","2023-04-20",null,null,"2024-08-21","Application still in PE Review status. Jen Videan"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Medicare","Participating","Enrollment Complete","2021-03-01",null,null,"2021-05-24","5/24/2021 Received approval notice from CMS and forwarded to Terri Craig for her records, along with the approved record from PECOS.  KFrazier"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Rail Road Medicare","Participating","Enrollment Complete","2008-04-19",null,"P01863839","2021-06-24","6/24/2021 Pulled RR Medicare on group level and received approval of RR PTAN P01863839 effective 4/19/2008. KFrazier"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 1/7/2021. KFrazier"]
["Lawrence A Wilson, MD",null,"Aetna","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 1/7/2021. KFrazier"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Aetna","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"Aetna","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",null,"IMS","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","IMS","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"IMS","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12",null,null,"2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12",null,null,"2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD","PE - WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12",null,null,"2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Boon Chapman","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",null,"Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",null,"Omni PPO","Participating","Add Info Submitted","2021-01-07",null,null,"2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","TriCare Standard","Participating","Enrollment Complete","2021-06-30",null,null,"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","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2021-01-07",null,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 1/7/2021.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Wellmed","Participating","Enrollment Complete","2021-08-24",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/24/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete","2021-05-01",null,null,"2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","Cigna","Participating","Enrollment Complete","2020-12-01",9800227,null,"2021-11-29","11/29/21 Recevied email from pdmcogz@cigna.com, provider is effective as of 12/01/2020. PID 9800227. Cbankston"]

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["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06",null,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09",null,null,"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","PE - City of Midland Health Department","TriCare Standard","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-01","Enrollment is set up as an ambulatory enrollment and providers can not be added to it. MS"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2023-10-09",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"HealthSmart PPO","Participating","Add Info Submitted","2023-10-09",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","USA PPO","In Process","Payor Follow Up",null,null,null,"2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06",null,null,"2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06",null,null,"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",null,"IMS","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"IMS","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete","2023-10-09",null,null,"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","PE - City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-20",null,null,"2024-01-09","Received confirmation via self service portal. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Wellmed","In Process","Payor Follow Up",null,null,null,"2024-07-08","Sent email to payor requesting status update. PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required",null,null,null,"2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",null,"IMS","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","IMS","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"IMS","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01",null,null,"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","PE - City of Midland Health Department","Scott&White (First Care)","In Process","Payor Follow Up",null,null,null,"2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-01",null,null,"2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2024-02-06",null,null,"2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",null,"Multiplan","Participating","Enrollment Complete","2024-02-06",null,null,"2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Multiplan","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-06",null,null,"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",null,"Omni PPO","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Omni PPO","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02",null,null,"2024-02-28","Re-Cred has been completed eff 1/2/2024. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",null,"Omni PPO","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Omni PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06",null,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06",null,null,"2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21",null,null,"2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - City of Midland Health Department","Cigna","Participating","Enrollment Complete","2024-02-01",446524,null,"2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-11-01",null,null,"2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2024-02-06",null,null,"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","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"HealthSmart PPO","Participating","Add Info Submitted","2024-02-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2023-11-06",null,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Multiplan","Participating","Add Info Submitted","2023-11-06",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed",null,null,null,"2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Medicaid","Participating","Enrollment Complete","2024-09-03",null,null,"2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06",920011605,null,"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","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-10-09",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06",null,null,"2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up",null,null,null,"2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","Amerigroup","In Process","Add Info Submitted",null,null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-04-25",null,null,"2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2024-04-01",null,null,"2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",null,"First Health Coventry","Participating","Enrollment Complete","2024-04-01",null,null,"2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted","2024-04-01",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"First Health Coventry","Participating","Add Info Submitted","2024-04-01",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06",8925217,null,"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","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20",null,null,"2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20",null,null,"2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",null,"Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20",null,null,"2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01",null,null,"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","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-10-09",null,null,"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","PE - City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25",null,null,"2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889",null,"2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD",null,"Aetna","Participating","Enrollment Complete","2024-02-06",null,null,"2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","PE - City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06",null,null,"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",null,"Aetna","Participating","Payor Follow Up","2024-02-06",null,null,"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","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up",null,null,null,"2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01",446524,null,"2023-12-04","Received approval email effective 12/01/23. MS"]