Provider Demographics
NPI:1366557159
Name:HAMILTON, BRENDA A (LSA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:A
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151617
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78715
Mailing Address - Country:US
Mailing Address - Phone:512-636-9641
Mailing Address - Fax:512-292-7889
Practice Address - Street 1:7310 MANCHACA RD #151617
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78715
Practice Address - Country:US
Practice Address - Phone:512-292-7889
Practice Address - Fax:512-292-7889
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
TXSA00075246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0076JROtherBCBS
TXSA00075OtherLICENSE NUMBER