Provider Demographics
NPI:1891123758
Name:CARRASCO, MALLORY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2626 S LOOP W STE 265
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-5636
Mailing Address - Country:US
Mailing Address - Phone:713-796-9955
Mailing Address - Fax:281-754-4524
Practice Address - Street 1:2626 S LOOP W STE 265
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-5636
Practice Address - Country:US
Practice Address - Phone:713-796-9955
Practice Address - Fax:281-754-4524
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08671363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX333252001Medicaid