Provider Demographics
NPI:1629095559
Name:PEREZ, SUE ELLEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ELLEN
Last Name:PEREZ
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:713-486-9800
Mailing Address - Fax:
Practice Address - Street 1:23910 KATY FWY STE 201
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1477
Practice Address - Country:US
Practice Address - Phone:713-486-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000337207K00000X
PAMA052372363A00000X
TXPA12152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE017642A48Medicaid
DE017642A48Medicare ID - Type Unspecified
DE017642A48Medicaid