=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669010773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY C SNYDER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2019
-----------------------------------------------------
Last Update Date | 07/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 HOSPITAL PKWY STE 210
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76022-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-835-9379
-----------------------------------------------------
Fax | 817-355-4515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 HOSPITAL PKWY STE 210
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76022-5936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-835-9379
-----------------------------------------------------
Fax | 817-355-4515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA13244
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------