Provider Demographics
NPI:1912244419
Name:ELLIOTT, DEBRA R (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:R
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2520 BF TERRY BLVD.
Mailing Address - Street 2:FM 2218
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471
Mailing Address - Country:US
Mailing Address - Phone:281-342-6006
Mailing Address - Fax:281-239-7554
Practice Address - Street 1:2520 BF TERRY BLVD.
Practice Address - Street 2:FM 2218
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471
Practice Address - Country:US
Practice Address - Phone:281-342-6006
Practice Address - Fax:281-239-7554
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320991801Medicaid
TX8409NAOtherBC/BS #
TX320991801Medicaid