Provider Demographics
NPI:1013175876
Name:ANDRADE, MARVIN A (PA)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:A
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11811 FALLBROOK DR STE B-2
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-3507
Mailing Address - Country:US
Mailing Address - Phone:832-237-8882
Mailing Address - Fax:832-237-8886
Practice Address - Street 1:11811 FALLBROOK DR STE B-2
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3507
Practice Address - Country:US
Practice Address - Phone:832-237-8882
Practice Address - Fax:832-237-8886
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA05379OtherSTATE LICENSE
TX742797464OtherTIN # RIO CLINIC
TXPA05379OtherSTATE LICENSE