Provider Demographics
NPI:1649568411
Name:CONCHO PHYSICIAN ASSISTANT PLACEMENT SERVICES
Entity Type:Organization
Organization Name:CONCHO PHYSICIAN ASSISTANT PLACEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-226-3503
Mailing Address - Street 1:PO BOX 4026
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-4026
Mailing Address - Country:US
Mailing Address - Phone:325-226-3503
Mailing Address - Fax:325-617-4446
Practice Address - Street 1:1633 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6848
Practice Address - Country:US
Practice Address - Phone:325-226-3503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05955363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8L9846Medicare PIN