Provider Demographics
NPI:1467725630
Name:DUBOSE, GWENDOLYN MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:MARIE
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:601 RIVER POINTE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2945
Mailing Address - Country:US
Mailing Address - Phone:936-788-6060
Mailing Address - Fax:936-788-6061
Practice Address - Street 1:601 RIVER POINTE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2945
Practice Address - Country:US
Practice Address - Phone:936-788-6060
Practice Address - Fax:936-788-6061
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant