=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912245184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW MICHAEL DE LA VEGA PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2013
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 W PLEASANT RUN RD
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104-5402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-531-7813
-----------------------------------------------------
Fax | 214-421-4804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1341 W MOCKINGBIRD LN STE 600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75247-6913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-531-7813
-----------------------------------------------------
Fax | 214-421-4804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA08274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------