Provider Demographics
NPI:1548686819
Name:LONGORIA, SANDRA (PA)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:LONGORIA
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 1:800 W JEFFERSON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-6329
Mailing Address - Country:US
Mailing Address - Phone:956-574-0431
Mailing Address - Fax:956-541-1011
Practice Address - Street 1:800 W JEFFERSON ST
Practice Address - Street 2:STE 200
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-6329
Practice Address - Country:US
Practice Address - Phone:956-574-0431
Practice Address - Fax:956-541-1011
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138708611Medicaid
TX342162001Medicaid
TX382245YLPSOtherWELLMED PTAN
TX138708613Medicaid
TX00R945OtherMEDICARE