Healthcare Provider Details

I. General information

NPI: 1750686606
Provider Name (Legal Business Name): ELLEN S MERCADO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 SWEETWATER BLVD ST #200
SUGAR LAND TX
77479-3467
US

IV. Provider business mailing address

2723 POLK ST
HOUSTON TX
77003-4536
US

V. Phone/Fax

Practice location:
  • Phone: 281-565-0033
  • Fax:
Mailing address:
  • Phone: 281-565-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07104
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: