Provider Demographics
NPI:1922402841
Name:CIVITELLO, ALICE (PA - C)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:CIVITELLO
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 1:1 BAYLOR PLZ
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3411
Mailing Address - Country:US
Mailing Address - Phone:713-798-4951
Mailing Address - Fax:
Practice Address - Street 1:6620 MAIN ST
Practice Address - Street 2:STE 1225
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2348
Practice Address - Country:US
Practice Address - Phone:713-798-2545
Practice Address - Fax:713-798-2578
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00385363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00385OtherTEXAS MEDICAL LICENSE