Provider Demographics
NPI:1780044834
Name:BROUILLETTE, GARY REED (FNP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:REED
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:FNP
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 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:039-273-7829
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:705 S GROVE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5220
Practice Address - Country:US
Practice Address - Phone:903-472-7307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP130058OtherTX LICENSE