Provider Demographics
NPI:1740789106
Name:LOWERY, BRENTTON TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENTTON
Middle Name:TYLER
Last Name:LOWERY
Suffix:
Gender:M
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 1:1220 MANUFACTURING ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-6506
Mailing Address - Country:US
Mailing Address - Phone:214-663-2526
Mailing Address - Fax:
Practice Address - Street 1:1220 MANUFACTURING ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75207-6506
Practice Address - Country:US
Practice Address - Phone:214-663-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPA5156363A00000X
DEC5-0011742363A00000X
LAPA334118363A00000X
OKPA4768363A00000X
WI5279-23363A00000X
FLPA9113811363A00000X
KYTC955363A00000X
MAPA7792363A00000X
KYPA2693363A00000X
IL085.007951363A00000X
NJ25MP00598300363A00000X
TX12161363A00000X
NY25363363A00000X
NC10455363A00000X
CA55346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant