Provider Demographics
NPI:1578172151
Name:BENNER, RYAN ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ELIZABETH
Last Name:BENNER
Suffix:
Gender:F
Credentials:PA
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 974985
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75397-4242
Mailing Address - Country:US
Mailing Address - Phone:817-263-0007
Mailing Address - Fax:817-263-1118
Practice Address - Street 1:6844 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-263-0007
Practice Address - Fax:817-263-1118
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant