Provider Demographics
NPI:1164818647
Name:ALI, NIDA (PA-C)
Entity Type:Individual
Prefix:
First Name:NIDA
Middle Name:
Last Name:ALI
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 1:6400 FANNIN STREET, SUITE 1700
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5420 WEST LOOP S STE 2400
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2118
Practice Address - Country:US
Practice Address - Phone:713-486-7528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347381102Medicaid
TX437147YKQHMedicare PIN