Provider Demographics
NPI:1720486863
Name:WILCHES, SERVIO ANDRES (PA-C)
Entity Type:Individual
Prefix:
First Name:SERVIO
Middle Name:ANDRES
Last Name:WILCHES
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 1:122 W JOHN CARPENTER FWY STE 420
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2014
Mailing Address - Country:US
Mailing Address - Phone:516-761-0812
Mailing Address - Fax:
Practice Address - Street 1:6812 HARRISBURG BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77011-4626
Practice Address - Country:US
Practice Address - Phone:713-715-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017877-1363A00000X
TXPA11189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant