Basic Information
| Provider Information | |||||||||
| NPI: | 1558450064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEDGEPETH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CLINTON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5858 CREEKWAY ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782475416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105906953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8401 DATAPOINT DR | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106140180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/07/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA02868 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA02868 | 01 | TX | TEXAS STATE BOARD LICENSE | OTHER |