Provider Demographics
NPI:1285694026
Name:DE LA ROSA, FABIAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:FABIAN
Middle Name:
Last Name:DE LA ROSA
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:4801 ALBERTA AVE.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-7333
Practice Address - Fax:915-545-7338
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP.A. 04215363AM0700X
TXPA04215363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181191103Medicaid
NM97507725Medicare PIN
TX8L27428Medicare PIN
TX181191103Medicaid
TXQ30744Medicare UPIN