Provider Demographics
NPI:1073784245
Name:ELIZONDO, EPIFANIO (PA-C)
Entity Type:Individual
Prefix:
First Name:EPIFANIO
Middle Name:
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:EPI
Other - Middle Name:
Other - Last Name:ELIZONDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:204 MEADOW CREEK LN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7960
Mailing Address - Country:US
Mailing Address - Phone:817-447-7788
Mailing Address - Fax:214-767-3209
Practice Address - Street 1:1711 DOOLITTLE AVE
Practice Address - Street 2:NAS JRB BRANCH CLINIC
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127-1133
Practice Address - Country:US
Practice Address - Phone:817-782-5923
Practice Address - Fax:817-782-5949
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant