Provider Demographics
NPI:1346418076
Name:WAUSON, MARCUS JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:JOHN
Last Name:WAUSON
Suffix:
Gender:M
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 N HEWITT DR
Practice Address - Street 2:
Practice Address - City:HEWITT
Practice Address - State:TX
Practice Address - Zip Code:76643-3038
Practice Address - Country:US
Practice Address - Phone:254-420-5000
Practice Address - Fax:254-420-5007
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA05661363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8K6727Medicare PIN