Provider Demographics
NPI:1245097799
Name:TICE, TREVOR (PA-C)
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:
Last Name:TICE
Suffix:
Gender:M
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 1:12221 MERIT DR STE 620
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-3222
Mailing Address - Country:US
Mailing Address - Phone:866-552-4866
Mailing Address - Fax:
Practice Address - Street 1:400 W ARBROOK BLVD STE 320
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3180
Practice Address - Country:US
Practice Address - Phone:866-552-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17968363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical