Provider Demographics
NPI:1790764678
Name:DUSENBERRY, DOUGLAS IVAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:IVAN
Last Name:DUSENBERRY
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3851 ROGER BROOKE DR
Mailing Address - Street 2:BROOKE ARMY MEDICAL CENTER
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:210-916-0517
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2021-08-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXPA04877363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical