Basic Information
| Provider Information | |||||||||
| NPI: | 1871979674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUDERS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 GABLES CT STE 201 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750757648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693265115 | ||||||||
| FaxNumber: | 4693265119 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 HIGHWAY 121 STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760345929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175027411 | ||||||||
| FaxNumber: | 8175027412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MS3663336 | 01 | TX | DEA | OTHER | 8874NV | 01 | TX | BCBS | OTHER |