Provider Demographics
NPI:1396027306
Name:LIVELY, AUDREY C (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:C
Last Name:LIVELY
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 ST STE 1700
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1526
Mailing Address - Country:US
Mailing Address - Phone:713-486-6998
Mailing Address - Fax:
Practice Address - Street 1:6414 FANNIN ST STE G150
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1514
Practice Address - Country:US
Practice Address - Phone:713-486-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07450363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical