Provider Demographics
NPI:1992846323
Name:BENNETT, MARCIE (PA)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:BENNETT
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 1:4775 HAMILTON WOLFE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3456
Mailing Address - Country:US
Mailing Address - Phone:210-616-0283
Mailing Address - Fax:210-616-0071
Practice Address - Street 1:4775 HAMILTON WOLFE RD STE 1
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3456
Practice Address - Country:US
Practice Address - Phone:210-616-0283
Practice Address - Fax:210-616-0071
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02823OtherLICENSE
TXPA02823OtherLICENSE
TXQ25840Medicare UPIN