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1063356459 NPI number — AGEWELL DERMATOLOGY, PLLC

NPI Number: 1063356459
Health Care Provider/Practitioner: AGEWELL DERMATOLOGY, PLLC

Information about “1063356459” NPI (AGEWELL DERMATOLOGY, PLLC) exists in 1063356459 in HTML format HTML  |  1063356459 in plain Text format TXT  |  1063356459 in PDF (Portable Document Format) PDF  |  1063356459 in an XML format XML  formats.

NPI Number : 1063356459 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1063356459",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "AGEWELL DERMATOLOGY, PLLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "12320 BARKER CYPRESS RD STE 600-1012",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "CYPRESS",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "77429-8325",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "12320 BARKER CYPRESS RD STE 600-1012",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "CYPRESS",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "77429-8325",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "281-685-1005",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "04/16/2026",
    "LastUpdateDate": "04/16/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "BRITTAIN",
    "AuthorizedOfficialFirstName": "ERIC",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "MANAGING MEMBER",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "MD",
    "AuthorizedOfficialTelephoneNumber": "843-860-7703",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "363A00000X",
        "TaxonomyName": "Physician Assistant",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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