Healthcare Provider Details

I. General information

NPI: 1568783553
Provider Name (Legal Business Name): ADVANCED FOOT AND ANKLE ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6312 AZLE AVE
LAKE WORTH TX
76135-2442
US

IV. Provider business mailing address

6312 AZLE AVE
LAKE WORTH TX
76135-2442
US

V. Phone/Fax

Practice location:
  • Phone: 817-238-8400
  • Fax: 817-238-8401
Mailing address:
  • Phone: 817-238-8400
  • Fax: 817-238-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1916
License Number StateTX

VIII. Authorized Official

Name: DR. RUSSELL OLIN PENDLETON
Title or Position: OWNER/PHYSICIAN
Credential: DPM
Phone: 817-238-8400