Provider Demographics
NPI:1043662034
Name:VALDIVIEZO, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:VALDIVIEZO
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 1:2046 FOREST LN STE 130
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-7996
Mailing Address - Country:US
Mailing Address - Phone:975-494-4494
Mailing Address - Fax:972-494-4450
Practice Address - Street 1:2046 FOREST LN STE 130
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042
Practice Address - Country:US
Practice Address - Phone:975-494-4494
Practice Address - Fax:972-494-4450
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11137363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant