Provider Demographics
NPI:1013153147
Name:PROKOP-FETTIG, DONNA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:PROKOP-FETTIG
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:PO BOX 268945
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8945
Mailing Address - Country:US
Mailing Address - Phone:512-388-1861
Mailing Address - Fax:512-388-0373
Practice Address - Street 1:1201 SAM BASS RD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4137
Practice Address - Country:US
Practice Address - Phone:512-388-1861
Practice Address - Fax:512-388-0373
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06103363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2028235-02Medicaid
TX2028235-01Medicaid
TX2028235-01Medicaid
TX2028235-02Medicaid