Healthcare Provider Details

I. General information

NPI: 1619584224
Provider Name (Legal Business Name): LUCY MAE BENNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5917 CROSSTOWN EXPRESSWAY SH 286
CORPUS CHRISTI TX
78417
US

IV. Provider business mailing address

5917 CROSSTOWN EXPRESSWAY SH 286
CORPUS CHRISTI TX
78417
US

V. Phone/Fax

Practice location:
  • Phone: 361-854-0811
  • Fax: 361-806-5040
Mailing address:
  • Phone: 361-854-0811
  • Fax: 361-806-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9113590
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA15351
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15351
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113590
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: