Basic Information
| Provider Information | |||||||||
| NPI: | 1346520681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYERAS | ||||||||
| FirstName: | ARA MARIE | ||||||||
| MiddleName: | AVECILLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUELIZA | ||||||||
| OtherFirstName: | ARA MARIE | ||||||||
| OtherMiddleName: | AVECILLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 840853 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752840865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7134584229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2011 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 1209 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 1209 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01095323 | 01 | TX | RAILROAD MEDICARE | OTHER | 339182301 | 05 | TX | MEDICAID |