Provider Demographics
NPI:1023035029
Name:BREKKEN, MARIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:BREKKEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-280-4375
Mailing Address - Fax:701-461-5764
Practice Address - Street 1:1720 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-280-4375
Practice Address - Fax:701-461-5764
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0143208100000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
R98240Medicare UPIN