Provider Demographics
NPI:1316189087
Name:BREWER, BRENT (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BREWER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-2436
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant