Basic Information
| Provider Information | |||||||||
| NPI: | 1336223288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | ORVIAL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4333 N JOSEY LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723944500 | ||||||||
| FaxNumber: | 9723948180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4333 N JOSEY LN STE 104 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723944500 | ||||||||
| FaxNumber: | 9723948180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00212 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 184447404 | 05 | TX | MEDICAID | 184447402 | 05 | TX | MEDICAID | 184447403 | 05 | TX | MEDICAID |