Provider Demographics
NPI:1073289500
Name:KATZ, BRENT WICKER (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:WICKER
Last Name:KATZ
Suffix:
Gender:M
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 1:1178 HINEMLU ST
Mailing Address - Street 2:PO BOX 500409
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950
Mailing Address - Country:US
Mailing Address - Phone:670-234-8951
Mailing Address - Fax:
Practice Address - Street 1:1178 HINEMLU ST
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-0409
Practice Address - Country:US
Practice Address - Phone:670-234-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006841363AM0700X
MP124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical