Basic Information
| Provider Information | |||||||||
| NPI: | 1679723514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTENCOURT | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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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 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA06577 | 01 | TX | STATE LICENSE | OTHER |