Healthcare Provider Details

I. General information

NPI: 1184847337
Provider Name (Legal Business Name): BRENT JAY MEREDITH P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 05/19/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MP 123 GLENN HWY
TOK AK
99780
US

IV. Provider business mailing address

PO BOX 647 134 S MESQUITE ST
MUENSTER TX
76252-0647
US

V. Phone/Fax

Practice location:
  • Phone: 907-883-5855
  • Fax:
Mailing address:
  • Phone: 940-759-2502
  • Fax: 940-759-3608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01436
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: