Provider Demographics
NPI:1912245184
Name:DE LA VEGA, ANDREW MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:DE LA VEGA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1341 W MOCKINGBIRD LN STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-6913
Mailing Address - Country:US
Mailing Address - Phone:214-531-7813
Mailing Address - Fax:214-421-4804
Practice Address - Street 1:224 W PLEASANT RUN RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-5402
Practice Address - Country:US
Practice Address - Phone:214-531-7813
Practice Address - Fax:214-421-4804
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA08274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8597NCOtherBCBS
TXTXB140060OtherGROUP PTAN
TXP01198637OtherRAILROAD
TX288043YNEAOtherIND PTAN