Provider Demographics
NPI:1952408742
Name:FLETCHER, BRIAN DOUGLAS (PAC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:FLETCHER
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 1:250 KING OF PRUSSIA RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5235
Mailing Address - Country:US
Mailing Address - Phone:610-902-5600
Mailing Address - Fax:610-902-5604
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5235
Practice Address - Country:US
Practice Address - Phone:610-902-5600
Practice Address - Fax:610-902-5604
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART003324174400000X
PATMA052617363AS0400X
PAMA055419363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical