Provider Demographics
NPI:1811442593
Name:SAUCEDO, IVANNA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:IVANNA
Middle Name:ELIZABETH
Last Name:SAUCEDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:IVANNA
Other - Middle Name:ELIZABETH
Other - Last Name:ECKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3320 OAKWELL CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3128
Mailing Address - Country:US
Mailing Address - Phone:210-829-5180
Mailing Address - Fax:210-314-8315
Practice Address - Street 1:3320 OAKWELL CT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3019
Practice Address - Country:US
Practice Address - Phone:210-829-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10737363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376912701Medicaid
TXPA10737OtherTEXAS LICENSE