=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396207031
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROWDY DWIGHT SARRETT PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2019
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4402 BROADWAY BLVD STE 1
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75043-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-240-1789
-----------------------------------------------------
Fax | 972-240-5525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4402 BROADWAY BLVD STE 1
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75043-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-240-1789
-----------------------------------------------------
Fax | 214-575-9929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | PA12726
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------