Healthcare Provider Details

I. General information

NPI: 1093781304
Provider Name (Legal Business Name): GLEN S FARRIS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E COURT ST
NEWTON TX
75966-3203
US

IV. Provider business mailing address

RR 1 BOX 42
JASPER TX
75951-9801
US

V. Phone/Fax

Practice location:
  • Phone: 409-379-2647
  • Fax: 409-379-2698
Mailing address:
  • Phone: 409-384-8089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00499
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: