Healthcare Provider Details

I. General information

NPI: 1205186152
Provider Name (Legal Business Name): CARRIE MICHAEL BUBENZER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 8500 LOCKBOX 7642
PHILADELPHIA PA
19178-5682
US

IV. Provider business mailing address

8731 PARK PLAZA DR
SHREVEPORT LA
71105-5682
US

V. Phone/Fax

Practice location:
  • Phone: 318-226-3300
  • Fax: 318-424-7610
Mailing address:
  • Phone: 318-797-5848
  • Fax: 318-797-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200579
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: