Provider Demographics
NPI:1326631094
Name:BREWER, CONNETT (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNETT
Middle Name:
Last Name:BREWER
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 1:4580 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CA
Mailing Address - Zip Code:90058-2208
Mailing Address - Country:US
Mailing Address - Phone:323-584-0779
Mailing Address - Fax:323-584-2282
Practice Address - Street 1:4580 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CA
Practice Address - Zip Code:90058-2208
Practice Address - Country:US
Practice Address - Phone:323-584-0779
Practice Address - Fax:323-584-2282
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY026643363A00000X
CAPA59710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant