Provider Demographics
NPI:1639331325
Name:EVERETT, ELIZABETH MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:LEEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:12221 MERIT DR
Mailing Address - Street 2:STE 1610
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2202
Mailing Address - Country:US
Mailing Address - Phone:214-217-1911
Mailing Address - Fax:214-217-1912
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:STE 1610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1911
Practice Address - Fax:214-217-1912
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280829701Medicaid
TX280829703Medicaid
TX280829703Medicaid
TXTXB126762Medicare PIN
TXTXB126758Medicare PIN
TXTXB126759Medicare PIN