Provider Demographics
NPI:1679737431
Name:PECO, GREGORY A (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:PECO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 LA CROSSE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78739-1783
Mailing Address - Country:US
Mailing Address - Phone:512-877-5333
Mailing Address - Fax:503-954-2122
Practice Address - Street 1:5915 LA CROSSE AVE STE 140
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78739-1783
Practice Address - Country:US
Practice Address - Phone:512-877-5333
Practice Address - Fax:503-954-2122
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1295041820Medicaid
8L12634Medicare PIN
1083861231OtherNPI
TX760465919OtherTAX ID
8L12632Medicare PIN
8L12631Medicare PIN