Basic Information
| Provider Information | |||||||||
| NPI: | 1639331325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEEKER | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12221 MERIT DR | ||||||||
| Address2: | STE 1610 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171911 | ||||||||
| FaxNumber: | 2142171912 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MERIT DR | ||||||||
| Address2: | STE 1610 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171911 | ||||||||
| FaxNumber: | 2142171912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05805 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 280829701 | 05 | TX | MEDICAID | 280829703 | 05 | TX | MEDICAID |