Basic Information
Provider Information | |||||||||
NPI: | 1558485862 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PENDLETON | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PENDLETON | ||||||||
OtherFirstName: | BRIAN | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 12221 MERIT DRIVE | ||||||||
Address2: | SUITE 1610 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752512204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2142171911 | ||||||||
FaxNumber: | 2142171912 | ||||||||
Practice Location | |||||||||
Address1: | 713 E. ANDERSON STREEET | ||||||||
Address2: |   | ||||||||
City: | WEATHERFOOD | ||||||||
State: | TX | ||||||||
PostalCode: | 760865705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173412273 | ||||||||
FaxNumber: | 8175991826 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2007 | ||||||||
LastUpdateDate: | 11/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03186 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | P01081371 | 01 | TX | RAILROAD | OTHER | 214537701 | 05 | TX |   | MEDICAID |