MEDICARE: RICHARD ALLEN BRANDT JR. PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA04130	TX

General Provider Information

NPI Number	:	1861651754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD ALLEN BRANDT JR. PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	715 N FIELDER RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-4695
Country	:	US
Telephone Number	:	817-261-1626
Fax Number	:	817-275-0441

Provider Business Practice Location Address
First Line	:	715 N FIELDER RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-4695
Country	:	US
Telephone Number	:	817-261-1626
Fax Number	:	817-275-0441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	06/05/2008

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