Provider Demographics
NPI:1659841237
Name:PAVIA-JIMENEZ, ANDREA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PAVIA-JIMENEZ
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 1:3230 I 30 STE 100
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2662
Mailing Address - Country:US
Mailing Address - Phone:972-682-1791
Mailing Address - Fax:
Practice Address - Street 1:610 W CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5419
Practice Address - Country:US
Practice Address - Phone:214-501-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX403452201Medicaid
TXPA12535OtherPA LICENSE
TXPA12535OtherPA LICENSE