Provider Demographics
NPI:1164654737
Name:CHILDRESS, ADRIAN DENISE (PA-C)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:DENISE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 N HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-2091
Mailing Address - Country:US
Mailing Address - Phone:903-438-1110
Mailing Address - Fax:903-438-1107
Practice Address - Street 1:1317 N HILLCREST DR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2091
Practice Address - Country:US
Practice Address - Phone:903-438-1110
Practice Address - Fax:903-438-1107
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281003801Medicaid
TX281003803Medicaid
TX752950731OtherTAX ID
TX281003801Medicaid