Provider Demographics
NPI:1053597989
Name:LANDAVAZO, DANA LYNNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LYNNE
Last Name:LANDAVAZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DANA
Other - Middle Name:LYNNE
Other - Last Name:MAILEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:10601 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76244-2118
Practice Address - Country:US
Practice Address - Phone:817-347-2600
Practice Address - Fax:817-247-2650
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB140062OtherGROUP PTAN
TXTXB140062OtherGROUP PTAN
TX347843YNEAMedicare PIN