Provider Demographics
NPI:1093780553
Name:STERRITT, CONNIE (PA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:STERRITT
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 1:4419 FRONTIER TRL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1686
Mailing Address - Country:US
Mailing Address - Phone:512-444-7208
Mailing Address - Fax:512-444-2343
Practice Address - Street 1:4419 FRONTIER TRL
Practice Address - Street 2:SUITE 110
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1686
Practice Address - Country:US
Practice Address - Phone:512-444-7208
Practice Address - Fax:512-444-2343
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02177207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX970013464OtherMEDICARE RAILROAD
TX83N007Medicare ID - Type Unspecified
TXS84381Medicare UPIN