1205015633 NPI number — JAMIE M BROWN PA-C

Table of content: JAMIE M BROWN PA-C (NPI 1205015633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205015633 NPI number — JAMIE M BROWN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
JAMIE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
JAMIE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205015633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 GOLD DR S
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-232-7705
Provider Business Mailing Address Fax Number:
701-893-9046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 GOLD DR S
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-7705
Provider Business Practice Location Address Fax Number:
701-893-9046
Provider Enumeration Date:
11/02/2007

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: 363AM0700X , with the licence number:  PAC0375 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 968415100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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