Provider Demographics
NPI:1023042900
Name:DESANDRO, STEPHANIE D (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:D
Last Name:DESANDRO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:5656 KELLEY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77026-1967
Practice Address - Country:US
Practice Address - Phone:713-566-5775
Practice Address - Fax:713-566-5024
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03686363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181497201Medicaid
TX003182516OtherCSHCN
TX8N3838OtherBCBS
TX003182516OtherCSHCN
TX8N3838OtherBCBS
TX8A5518Medicare PIN