Provider Demographics
NPI:1083041321
Name:GEORGE, BENOY ABRAHAM (CSA, LSA)
Entity Type:Individual
Prefix:
First Name:BENOY
Middle Name:ABRAHAM
Last Name:GEORGE
Suffix:
Gender:M
Credentials:CSA, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-0123
Mailing Address - Country:US
Mailing Address - Phone:972-974-2993
Mailing Address - Fax:
Practice Address - Street 1:2611 TOWNLAKE DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8979
Practice Address - Country:US
Practice Address - Phone:972-974-2993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical