Provider Demographics
NPI:1336252220
Name:BENDECK, GUSTAVO ALONSO (PA)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALONSO
Last Name:BENDECK
Suffix:
Gender:M
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:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-2828
Mailing Address - Country:US
Mailing Address - Phone:806-767-1706
Mailing Address - Fax:
Practice Address - Street 1:4010 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1116
Practice Address - Country:US
Practice Address - Phone:806-767-1706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J8006Medicare PIN
TXS22607Medicare UPIN