Provider Demographics
NPI:1104100973
Name:AVALOS, EMILY (PA)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:
Last Name:AVALOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 ADMIRALITY WAY
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061
Mailing Address - Country:US
Mailing Address - Phone:469-995-9460
Mailing Address - Fax:
Practice Address - Street 1:5917 BELT LINE ROAD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254
Practice Address - Country:US
Practice Address - Phone:972-726-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant