Provider Demographics
NPI:1639611676
Name:ACEVEDO-SANTIAGO, ITXIA L (PA)
Entity Type:Individual
Prefix:
First Name:ITXIA
Middle Name:L
Last Name:ACEVEDO-SANTIAGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8442 FLINT CV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-4655
Mailing Address - Country:US
Mailing Address - Phone:214-384-7591
Mailing Address - Fax:
Practice Address - Street 1:1150 W 25TH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1830
Practice Address - Country:US
Practice Address - Phone:210-201-1159
Practice Address - Fax:432-221-4363
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10915363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical