MEDICARE: MARILYN CONDON 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	PA05731	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8Y9129	OTHER	TX	BC/BS

General Provider Information

NPI Number	:	1326025008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN CONDON PA-C

Provider Business Mailing Address
First Line	:	1411 N BECKLEY AVE
Second Line	:	PAV III STE#152
City	:	DALLAS
State	:	TX
Zip	:	75203-1259
Country	:	US
Telephone Number	:	214-948-2076
Fax Number	:	214-948-9990

Provider Business Practice Location Address
First Line	:	1411 N BECKLEY AVE
Second Line	:	PAV III STE#152
City	:	DALLAS
State	:	TX
Zip	:	75203-1259
Country	:	US
Telephone Number	:	214-948-2076
Fax Number	:	214-948-9990

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

Provider Enumeration Date	:	12/23/2005
Last Update Date	:	03/18/2010

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Directions to “ MARILYN CONDON PA-C” Practice Location

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