Provider Demographics
NPI:1275622649
Name:LOVE, ELISSA (PAC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:LOVE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 SAN FELIPE ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1711
Mailing Address - Country:US
Mailing Address - Phone:713-266-9955
Mailing Address - Fax:281-266-9956
Practice Address - Street 1:7575 SAN FELIPE ST
Practice Address - Street 2:SUITE 155
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-1711
Practice Address - Country:US
Practice Address - Phone:713-266-9955
Practice Address - Fax:281-266-9956
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8242NDOtherBLUE CROSS BLUE SHIELD
TX8242NDOtherBLUE CROSS BLUE SHIELD
S75656Medicare UPIN
TX8G1501Medicare PIN