Provider Demographics
NPI:1497997191
Name:BRECKE, REGAN M (PA)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:M
Last Name:BRECKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REGAN
Other - Middle Name:E
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4868 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2048
Mailing Address - Country:US
Mailing Address - Phone:757-483-7100
Mailing Address - Fax:757-483-7150
Practice Address - Street 1:4092 FOXWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5225
Practice Address - Country:US
Practice Address - Phone:757-467-4200
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840821363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
019060E07Medicare PIN