Provider Demographics
NPI:1720485212
Name:LASTRAPES, MICHELLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:LASTRAPES
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 1:12603 SOUTHWEST FWY STE 335
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3842
Mailing Address - Country:US
Mailing Address - Phone:281-269-6701
Mailing Address - Fax:
Practice Address - Street 1:12603 SOUTHWEST FWY STE 335
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3842
Practice Address - Country:US
Practice Address - Phone:281-269-6701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical