Provider Demographics
NPI:1356360101
Name:BENAVIDES, MELISSA (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3020 E HEBRON PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4457
Mailing Address - Country:US
Mailing Address - Phone:972-492-2776
Mailing Address - Fax:972-939-0971
Practice Address - Street 1:3020 E HEBRON PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4457
Practice Address - Country:US
Practice Address - Phone:972-492-2776
Practice Address - Fax:972-939-0971
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G1246Medicare PIN
TXTXB123621Medicare PIN
TXQ55598Medicare UPIN
TXTXB123625Medicare PIN
TXTXB123624Medicare PIN
TX8G1176Medicare PIN
TX8L23921Medicare PIN