Provider Demographics
NPI:1215094594
Name:DEWITT, DAVID WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WAYNE
Last Name:DEWITT
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 1:8008 BRONCO LN STE 1
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-4151
Mailing Address - Country:US
Mailing Address - Phone:512-267-1877
Mailing Address - Fax:512-267-1726
Practice Address - Street 1:8808 BRONCO LANE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAGO VISTA
Practice Address - State:TX
Practice Address - Zip Code:78645
Practice Address - Country:US
Practice Address - Phone:512-267-1877
Practice Address - Fax:512-267-1726
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07432363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3383028-01OtherWELLMED MEDICAID
TX319707YLPSOtherWELLMED MEDICARE