Provider Demographics
NPI:1336630136
Name:BRAITHWAITE, ALYCIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:BRAITHWAITE
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 1:3309 SHERRYE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-4670
Mailing Address - Country:US
Mailing Address - Phone:425-445-7077
Mailing Address - Fax:
Practice Address - Street 1:3500 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3460
Practice Address - Country:US
Practice Address - Phone:214-947-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant