Provider Demographics
NPI:1275851040
Name:NOWAKOWSKI, BREANNE J (PA)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:J
Last Name:NOWAKOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:J
Other - Last Name:SERGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2435 MCKINLEY AVE
Mailing Address - Street 2:VILLA SIERRA #73
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-2238
Mailing Address - Country:US
Mailing Address - Phone:631-942-7860
Mailing Address - Fax:915-569-1233
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-2131
Practice Address - Fax:915-569-2107
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013701-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant