Healthcare Provider Details

I. General information

NPI: 1780234096
Provider Name (Legal Business Name): STAN MEPURATH PHILIP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 S GOLIAD ST STE 110
ROCKWALL TX
75032-4903
US

IV. Provider business mailing address

2235 S GOLIAD ST STE 110
ROCKWALL TX
75032-4903
US

V. Phone/Fax

Practice location:
  • Phone: 469-495-9142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13090
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: