Provider Demographics
NPI:1609109552
Name:LANDRY, MARY ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALEXANDRA
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E JOHN CARPENTER FWY
Mailing Address - Street 2:SUITE 850
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-2727
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:972-957-3005
Practice Address - Street 1:8112 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-3829
Practice Address - Country:US
Practice Address - Phone:214-884-1705
Practice Address - Fax:214-884-1711
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04319OtherMEDICAL LICENSE