Healthcare Provider Details

I. General information

NPI: 1932559622
Provider Name (Legal Business Name): SERGIO VALLEJO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 8TH AVE
FORT WORTH TX
76104-3902
US

IV. Provider business mailing address

4013 DOGWOOD LN
FORT WORTH TX
76137-1715
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-5292
  • Fax:
Mailing address:
  • Phone: 562-519-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10579
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: