Provider Demographics
NPI:1972680858
Name:PEREZ, LETICIA R (MPAS, PA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:R
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MPAS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S INTERSTATE 35 STE 103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5700
Mailing Address - Country:US
Mailing Address - Phone:512-826-0773
Mailing Address - Fax:833-938-5463
Practice Address - Street 1:2800 S INTERSTATE 35 STE 103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5700
Practice Address - Country:US
Practice Address - Phone:512-826-0773
Practice Address - Fax:833-938-5463
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04895363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04895OtherTEXAS MEDICAL LIC.