Provider Demographics
NPI:1922488592
Name:BUITRAGO, ANNETTE (LSA)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:BUITRAGO
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 PIMA CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4646
Mailing Address - Country:US
Mailing Address - Phone:409-370-8466
Mailing Address - Fax:
Practice Address - Street 1:1703 PIMA CT
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573
Practice Address - Country:US
Practice Address - Phone:409-370-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA000587246ZC0007X
TX157449246ZC0007X
TXSA00587363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant