Provider Demographics
NPI:1912306028
Name:HERDMAN, GARRETT (PA-C)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:HERDMAN
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 1:2626 N BRYANT BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-2861
Mailing Address - Country:US
Mailing Address - Phone:412-235-5810
Mailing Address - Fax:
Practice Address - Street 1:2626 N BRYANT BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-2861
Practice Address - Country:US
Practice Address - Phone:256-581-5113
Practice Address - Fax:325-481-2166
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09984363A00000X
PAMA058994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103342569Medicaid