Provider Demographics
NPI:1518967504
Name:QUEVEDO, THAO T (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:THAO
Middle Name:T
Last Name:QUEVEDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THAO
Other - Middle Name:T
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5702 LAVON DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3126
Practice Address - Country:US
Practice Address - Phone:972-495-5595
Practice Address - Fax:972-675-5806
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179940503Medicaid
TX179940501Medicaid
TX8N4446OtherBLUE CROSS BLUE SHIELD
TX179940502Medicaid
TX179940502Medicaid
TX179940501Medicaid
TX179940503Medicaid