Provider Demographics
NPI:1407831100
Name:RODRIGUEZ, ANDREA WISE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:WISE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1600 W NORTHWEST HWY
Practice Address - Street 2:STE 900
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8112
Practice Address - Country:US
Practice Address - Phone:817-347-2530
Practice Address - Fax:817-488-5096
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190371802Medicaid
TX190371802Medicaid