Provider Demographics
NPI:1003113770
Name:SUSTAITA, AMY D
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:SUSTAITA
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 1:304 MEDIC LN
Mailing Address - Street 2:STE B
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-5894
Mailing Address - Country:US
Mailing Address - Phone:281-331-2062
Mailing Address - Fax:281-331-8070
Practice Address - Street 1:815 S WASHINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5316
Practice Address - Country:US
Practice Address - Phone:903-927-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA07123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX420661701Medicaid