Provider Demographics
NPI:1174945372
Name:WARNOCK, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:WARNOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 RICKETY LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1706
Mailing Address - Country:US
Mailing Address - Phone:903-533-8811
Mailing Address - Fax:903-533-8811
Practice Address - Street 1:820 S BAXTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2225
Practice Address - Country:US
Practice Address - Phone:903-592-6355
Practice Address - Fax:903-592-7680
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical