MEDICARE: SERVIO ANDRES WILCHES PA-C

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	017877-1	NY
2	363A00000X	Physician Assistant	PA11189	TX

General Provider Information

NPI Number	:	1720486863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERVIO ANDRES WILCHES PA-C

Provider Business Mailing Address
First Line	:	122 W JOHN CARPENTER FWY STE 420
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75039-2014
Country	:	US
Telephone Number	:	516-761-0812
Fax Number	:

Provider Business Practice Location Address
First Line	:	6812 HARRISBURG BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77011-4626
Country	:	US
Telephone Number	:	713-715-4460
Fax Number	:

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

Provider Enumeration Date	:	12/05/2014
Last Update Date	:	10/03/2017

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Directions to “ SERVIO ANDRES WILCHES PA-C” Practice Location

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