Healthcare Provider Details

I. General information

NPI: 1558485862
Provider Name (Legal Business Name): BRIAN ALLEN PENDLETON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BRIAN T PENDLETON PA

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E. ANDERSON STREEET
WEATHERFOOD TX
76086-5705
US

IV. Provider business mailing address

12221 MERIT DRIVE SUITE 1610
DALLAS TX
75251-2204
US

V. Phone/Fax

Practice location:
  • Phone: 817-341-2273
  • Fax: 817-599-1826
Mailing address:
  • Phone: 214-217-1911
  • Fax: 214-217-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03186
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: