Provider Demographics
NPI:1336650266
Name:BREWER, MADELINE (PA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2939 W DURANGO ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-6357
Mailing Address - Country:US
Mailing Address - Phone:505-330-2389
Mailing Address - Fax:
Practice Address - Street 1:3250 W LOWER BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-6729
Practice Address - Country:US
Practice Address - Phone:602-876-5596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6869363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical