Provider Demographics
NPI:1144450339
Name:GERDES, ELISA (PA)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:GERDES
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 1:4504 BOAT CLUB RD STE 800
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7002
Mailing Address - Country:US
Mailing Address - Phone:817-237-0515
Mailing Address - Fax:817-237-0611
Practice Address - Street 1:4504 BOAT CLUB RD STE 800
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7002
Practice Address - Country:US
Practice Address - Phone:817-237-0515
Practice Address - Fax:817-237-0611
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323195301Medicaid
TX323195301Medicaid