Provider Demographics
NPI:1073620621
Name:WITTENBURG, CHERYL B (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:B
Last Name:WITTENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-242-2267
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-791-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03466363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical