Organization
PURPLE AMPHIBIAN, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CECE J PANNELL (OFFICE MANAGER)
(817) 294-7444
Entity
Organization
Contact information
Practice address
7451 CHAPEL AVE, FORT WORTH, TX 76116-7090
(817) 926-2544
Mailing address
PO BOX 2626, FORT WORTH, TX 76113-2626
(817) 294-7444
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
648218
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0025KE
BCBS TX
TX
Enumeration date
08/05/2008
Last updated
06/17/2011
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