Provider Demographics
NPI:1710178017
Name:WISHON, IDALUPE (PAC)
Entity Type:Individual
Prefix:
First Name:IDALUPE
Middle Name:
Last Name:WISHON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N PEARL ST
Mailing Address - Street 2:SUITE N510
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2824
Mailing Address - Country:US
Mailing Address - Phone:214-580-7277
Mailing Address - Fax:214-580-7283
Practice Address - Street 1:2701 S HAMPTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-2367
Practice Address - Country:US
Practice Address - Phone:214-330-9221
Practice Address - Fax:214-999-9363
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02452OtherMEDICAL LICENSE- PAC
TX2052045-01Medicaid
TXPA02452OtherMEDICAL LICENSE- PAC