Basic Information
| Provider Information | |||||||||
| NPI: | 1467548743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775551385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722166 | ||||||||
| FaxNumber: | 4097722663 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775551385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722166 | ||||||||
| FaxNumber: | 4097722663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L7367 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 161919901 | 05 | TX | MEDICAID | 161919902 | 05 | TX | MEDICAID | 161919904 | 05 | TX | MEDICAID | 161919903 | 05 | TX | MEDICAID |