1639415136 NPI number — JAMIE SUZANNE BRAZER BCABA, LABA

Table of content: JAMIE SUZANNE BRAZER BCABA, LABA (NPI 1639415136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639415136 NPI number — JAMIE SUZANNE BRAZER BCABA, LABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAZER
Provider First Name:
JAMIE
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCABA, LABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639415136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 UNIVERSITY PLZ
Provider Second Line Business Mailing Address:
MAILSTOP 9450
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63701-4710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-225-5828
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 N FOUNTAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63701-7244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-225-5828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  2011024511 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2011024511 . This is a "STATE OF MISSOURI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".