Provider Demographics
NPI:1659444305
Name:ENGEL, ERIC BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:BRYAN
Last Name:ENGEL
Suffix:
Gender:M
Credentials:PA
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 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1106 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9164
Practice Address - Country:US
Practice Address - Phone:417-581-3548
Practice Address - Fax:417-581-6164
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014032125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y2074OtherBCBS
TX188436301Medicaid
MOPENDINGMedicare PIN
TX8Y2074OtherBCBS
TX188436301Medicaid