Provider Demographics
NPI:1861548778
Name:PEREZ, ALISSA J (PAC)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:J
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:J
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:1600 11TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301
Mailing Address - Country:US
Mailing Address - Phone:940-764-7000
Mailing Address - Fax:
Practice Address - Street 1:1600 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4300
Practice Address - Country:US
Practice Address - Phone:940-764-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001309363AM0700X
TXPA05746363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
52057B005OtherTRICARE
IA0109OtherJOHN DEERE HEALTHCARE
IA25402OtherBLUE SHIELD
P22303Medicare UPIN
I1134Medicare ID - Type Unspecified
IA0109OtherJOHN DEERE HEALTHCARE