Healthcare Provider Details

I. General information

NPI: 1518967504
Provider Name (Legal Business Name): THAO T. QUEVEDO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THAO T. NGUYEN PA-C

II. Dates (important events)

Enumeration Date: 07/30/2005
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5702 LAVON DR
GARLAND TX
75040-3126
US

IV. Provider business mailing address

5702 LAVON DR
GARLAND TX
75040-3126
US

V. Phone/Fax

Practice location:
  • Phone: 972-495-5595
  • Fax: 972-675-5806
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01763
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: