Provider Demographics
NPI:1821102088
Name:KALLEMEYN, BRITT DOUGLAS (PAC)
Entity Type:Individual
Prefix:
First Name:BRITT
Middle Name:DOUGLAS
Last Name:KALLEMEYN
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 2279
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-2279
Mailing Address - Country:US
Mailing Address - Phone:254-897-3444
Mailing Address - Fax:254-897-9973
Practice Address - Street 1:1008 NE BIG BEND TRL
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4912
Practice Address - Country:US
Practice Address - Phone:254-897-3444
Practice Address - Fax:254-897-9973
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S25424Medicare UPIN