Provider Demographics
NPI:1922146372
Name:BADGER, BRENT G (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:G
Last Name:BADGER
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:PO BOX 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-758-3598
Mailing Address - Fax:972-599-9604
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-6575
Practice Address - Fax:972-566-4703
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215674702Medicaid
TX215674701Medicaid
TXTXB105710Medicare PIN
TXTXB133356Medicare PIN
TX215674701Medicaid