Healthcare Provider Details

I. General information

NPI: 1457938524
Provider Name (Legal Business Name): BRENNA MARIE PARKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 BUDDY GANEM DR STE A
PORTLAND TX
78374-3202
US

IV. Provider business mailing address

277 BUDDY GANEM DR STE A
PORTLAND TX
78374-3202
US

V. Phone/Fax

Practice location:
  • Phone: 361-777-3900
  • Fax:
Mailing address:
  • Phone: 361-777-3900
  • Fax: 361-777-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV0501
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: