1548908874 NPI number — MR. EVAN BRADLEE BREWER CRNP

Table of content: MR. EVAN BRADLEE BREWER CRNP (NPI 1548908874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548908874 NPI number — MR. EVAN BRADLEE BREWER CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
EVAN
Provider Middle Name:
BRADLEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
M

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:
1548908874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 STERTHAUS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-5133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-406-1168
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3610 SPRINGHILL MEMORIAL DR N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-410-3600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2022

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: 363LF0000X , with the licence number:  APRN11019443 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 1-263328 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 115058500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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