Provider Demographics
NPI:1811403553
Name:TODD, ATHENA (PA-C)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:TODD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HWY 75
Mailing Address - Street 2:SUITE 300, ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4587
Mailing Address - Country:US
Mailing Address - Phone:903-416-6460
Mailing Address - Fax:
Practice Address - Street 1:3126 W FM 120
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1249
Practice Address - Country:US
Practice Address - Phone:903-416-7544
Practice Address - Fax:903-416-7545
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK2869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program