Healthcare Provider Details

I. General information

NPI: 1598201196
Provider Name (Legal Business Name): P A CORPORATE ENTERPRISES LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 HIGHWAY 45 BYP S
MEDINA TN
38355-9633
US

IV. Provider business mailing address

589 HIGHWAY 45 BYP S
MEDINA TN
38355-9633
US

V. Phone/Fax

Practice location:
  • Phone: 713-462-0000
  • Fax:
Mailing address:
  • Phone: 713-462-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DAVID JEFF WILBERT
Title or Position: OWNER
Credential: PA-C
Phone: 713-462-0000