Provider Demographics
NPI:1457318040
Name:BRECKE, STEFAN FRIEDRICH (PA)
Entity Type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:FRIEDRICH
Last Name:BRECKE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:2000 MEADE PKWY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-539-0251
Practice Address - Fax:757-934-9409
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA970009887OtherRAILROAD MEDICARE
VA8922951Medicaid
VA970009887OtherRAILROAD MEDICARE
VA8922951Medicaid