Provider Demographics
NPI:1164714440
Name:MARY WINBORN PA-C, PC
Entity Type:Organization
Organization Name:MARY WINBORN PA-C, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WINBORN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:469-438-9070
Mailing Address - Street 1:1314 POINSETTIA BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-7551
Mailing Address - Country:US
Mailing Address - Phone:469-438-9070
Mailing Address - Fax:
Practice Address - Street 1:1314 POINSETTIA BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-7551
Practice Address - Country:US
Practice Address - Phone:469-438-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285341802Medicaid
TX285341803Medicaid
TX285341801Medicaid
TXTXB133145Medicare PIN
TXTXB133144Medicare PIN
TX285341801Medicaid