MEDICARE: CARRIE MICHAEL BUBENZER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	200579	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12513166	OTHER		CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205186152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE MICHAEL BUBENZER PA-C

Provider Business Mailing Address
First Line	:	8731 PARK PLAZA DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5682
Country	:	US
Telephone Number	:	318-797-5848
Fax Number	:	318-797-5844

Provider Business Practice Location Address
First Line	:	PO BOX 8500 LOCKBOX 7642
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19178-5682
Country	:	US
Telephone Number	:	318-226-3300
Fax Number	:	318-424-7610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	08/16/2024

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