Provider Demographics
NPI:1407588809
Name:KVINTA, MARY INGEBORG (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:INGEBORG
Last Name:KVINTA
Suffix:
Gender:F
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 1:431 E STATE HIGHWAY 114 STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4416
Mailing Address - Country:US
Mailing Address - Phone:682-651-8181
Mailing Address - Fax:817-812-2868
Practice Address - Street 1:431 E STATE HIGHWAY 114 STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4416
Practice Address - Country:US
Practice Address - Phone:682-651-8181
Practice Address - Fax:817-812-2868
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant