Basic Information
| Provider Information | |||||||||
| NPI: | 1932559622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALLEJO | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 MIRROR LAKE DR | ||||||||
| Address2: | |||||||||
| City: | HALTOM CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761171325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625192254 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2016 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.