Provider Demographics
NPI:1144333113
Name:CLYDE, SARA M (PA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:CLYDE
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 1:11514 TARA PL
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7279
Mailing Address - Country:US
Mailing Address - Phone:832-588-2392
Mailing Address - Fax:713-792-1643
Practice Address - Street 1:1515 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-792-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180635802Medicaid
TX8Y0654OtherBCBS
TX8G7954Medicare PIN
TX8Y0654OtherBCBS