Provider Demographics
NPI:1073624839
Name:GRUBB, BETHANY LESCH (PA-C, MPAS)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:LESCH
Last Name:GRUBB
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:MISS
Other - First Name:BETHANY
Other - Middle Name:JANE
Other - Last Name:LESCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9749 GATECREST DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-3314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 W WHEATLAND RD
Practice Address - Street 2:STE. 225
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3470
Practice Address - Country:US
Practice Address - Phone:972-283-8979
Practice Address - Fax:972-283-8988
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03447363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
8B4327Medicare UPIN
TX8B4327Medicare ID - Type Unspecified