Basic Information
| Provider Information | |||||||||
| NPI: | 1659444305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGEL | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1106 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657219164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175813548 | ||||||||
| FaxNumber: | 4175816164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2014032125 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8Y2074 | 01 | TX | BCBS | OTHER | 188436301 | 05 | TX | MEDICAID |