MEDICARE: IDALUPE WISHON PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA02452	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA02452	OTHER	TX	MEDICAL LICENSE- PAC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710178017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDALUPE WISHON PAC

Provider Business Mailing Address
First Line	:	700 N PEARL ST STE N510
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-2863
Country	:	US
Telephone Number	:	214-580-7277
Fax Number	:	214-999-9363

Provider Business Practice Location Address
First Line	:	2701 S HAMPTON RD STE 101
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-2363
Country	:	US
Telephone Number	:	214-330-9221
Fax Number	:	214-999-9363

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	02/04/2026

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Directions to “ IDALUPE WISHON PAC” Practice Location

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