Provider Demographics
NPI:1184847337
Name:MEREDITH, BRENT JAY (PAC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JAY
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:134 S MESQUITE ST
Mailing Address - City:MUENSTER
Mailing Address - State:TX
Mailing Address - Zip Code:76252-0647
Mailing Address - Country:US
Mailing Address - Phone:940-759-2502
Mailing Address - Fax:940-759-3608
Practice Address - Street 1:MP 123 GLENN HWY
Practice Address - Street 2:
Practice Address - City:TOK
Practice Address - State:AK
Practice Address - Zip Code:99780
Practice Address - Country:US
Practice Address - Phone:907-883-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217002901Medicaid
TX217002901Medicaid