Provider Demographics
NPI:1295782498
Name:FELLER, VINCENT ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:ANTHONY
Last Name:FELLER
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 1:200 PECAN CRK
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6371
Mailing Address - Country:US
Mailing Address - Phone:817-481-4739
Mailing Address - Fax:
Practice Address - Street 1:3400 TEXAS SAGE TRL
Practice Address - Street 2:#148
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8603
Practice Address - Country:US
Practice Address - Phone:817-750-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA06351OtherTEXAS LICENSE
TXPA06351OtherTEXAS LICENSE