=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912964503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERIE BENNETT PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 06/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 W 10TH ST
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78621-2261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-229-3334
-----------------------------------------------------
Fax | 877-662-9957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1890
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78629-1390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-339-2093
-----------------------------------------------------
Fax | 830-282-6952
-----------------------------------------------------
=====================================================
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 | PA01240
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------