Provider Demographics
NPI:1326025008
Name:CONDON, MARILYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CONDON
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 1:1411 N BECKLEY AVE
Mailing Address - Street 2:PAV III STE#152
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1259
Mailing Address - Country:US
Mailing Address - Phone:214-948-2076
Mailing Address - Fax:214-948-9990
Practice Address - Street 1:1411 N BECKLEY AVE
Practice Address - Street 2:PAV III STE#152
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1259
Practice Address - Country:US
Practice Address - Phone:214-948-2076
Practice Address - Fax:214-948-9990
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199675301Medicaid
TX8Y9129OtherBC/BS
TX8Y9129OtherBC/BS
TX199675301Medicaid