Provider Demographics
NPI:1124000922
Name:BRIMLOW, JOHN P (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:BRIMLOW
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3340
Mailing Address - Country:US
Mailing Address - Phone:707-445-3063
Mailing Address - Fax:707-442-6602
Practice Address - Street 1:2505 LUCAS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3340
Practice Address - Country:US
Practice Address - Phone:707-445-3063
Practice Address - Fax:707-442-6602
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPA10060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28485ZOtherBLUE SHIELD
CAGR0067130Medicaid
CAZZZ28485ZOtherBLUE SHIELD
CAGR0067130Medicaid