Provider Demographics
NPI:1497261754
Name:BREW, HEATHER VIRGINIA
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:VIRGINIA
Last Name:BREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 MEDICAL WAY
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-5548
Mailing Address - Country:US
Mailing Address - Phone:863-386-0786
Mailing Address - Fax:
Practice Address - Street 1:3109 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5548
Practice Address - Country:US
Practice Address - Phone:863-386-0786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty