Provider Demographics
NPI:1780632885
Name:LITTLE, BENNIE
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:
Practice Address - Street 1:2606 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1818
Practice Address - Country:US
Practice Address - Phone:757-482-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230088367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX874140UOtherBCBSTX
TX874140UOtherBCBSTX