MEDICARE: RICHARD LEE ANSCHUTZ 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
2	363AM0700X	Medical Physician Assistant	PA04866	TX

General Provider Information

NPI Number	:	1265403695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD LEE ANSCHUTZ PA-C

Provider Business Mailing Address
First Line	:	23522 ROCKBROOK CV
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78261-2348
Country	:	US
Telephone Number	:	210-437-0266
Fax Number	:

Provider Business Practice Location Address
First Line	:	3851 ROGER BROOKE DR, MCHE-QD (CREDS),
Second Line	:	BROOKE ARMY MEDICAL CENTER
City	:	FT SAM HOUSTON
State	:	TX
Zip	:	78234-6200
Country	:	US
Telephone Number	:	210-916-3598
Fax Number	:

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	06/02/2009

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