Provider Demographics
NPI:1790247435
Name:DIVITA, ANDIE ELISABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDIE
Middle Name:ELISABETH
Last Name:DIVITA
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 1:1309 MARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-7069
Mailing Address - Country:US
Mailing Address - Phone:214-755-0066
Mailing Address - Fax:
Practice Address - Street 1:5550 WARREN PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7398
Practice Address - Country:US
Practice Address - Phone:214-755-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant