Provider Demographics
NPI:1609815828
Name:SUTHERLAND, ELIZABETH WYLIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:WYLIE
Last Name:SUTHERLAND
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 1:1515 HOLCOMBE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4000
Mailing Address - Country:US
Mailing Address - Phone:713-772-1058
Mailing Address - Fax:
Practice Address - Street 1:1155 PRESSLER ST UNIT 1286
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3721
Practice Address - Country:US
Practice Address - Phone:713-772-1058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04325363AM0700X, 363AS0400X
MDPA58950363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L4720Medicare PIN