Provider Demographics
NPI:1598192387
Name:ESTEGHAMATDARSHAD, BERNICE ZACNITE (PA)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:ZACNITE
Last Name:ESTEGHAMATDARSHAD
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:P.O. BOX 450329
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0329
Mailing Address - Country:US
Mailing Address - Phone:956-722-9918
Mailing Address - Fax:956-722-0829
Practice Address - Street 1:6801 MCPHERSON RD STE 331
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6417
Practice Address - Country:US
Practice Address - Phone:956-722-9918
Practice Address - Fax:956-722-0829
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08752363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328900101Medicaid
TX328900101Medicaid