Provider Demographics
NPI:1558485862
Name:PENDLETON, BRIAN ALLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ALLEN
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:T
Other - Last Name:PENDLETON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:12221 MERIT DRIVE
Mailing Address - Street 2:SUITE 1610
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2204
Mailing Address - Country:US
Mailing Address - Phone:214-217-1911
Mailing Address - Fax:214-217-1912
Practice Address - Street 1:713 E. ANDERSON STREEET
Practice Address - Street 2:
Practice Address - City:WEATHERFOOD
Practice Address - State:TX
Practice Address - Zip Code:76086-5705
Practice Address - Country:US
Practice Address - Phone:817-341-2273
Practice Address - Fax:817-599-1826
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01081371OtherRAILROAD
TX214537701Medicaid
TXTXB101261Medicare PIN