Provider Demographics
NPI:1568834893
Name:IVICEVICH, BRAELEN DAWN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BRAELEN
Middle Name:DAWN
Last Name:IVICEVICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6560 FANNIN, SCURLOCK TOWER
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:281-737-4560
Mailing Address - Fax:281-737-4561
Practice Address - Street 1:6560 FANNIN
Practice Address - Street 2:SCURLOCK TOWER, SUITE 2200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:281-737-4560
Practice Address - Fax:281-737-4561
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8266NTOtherBLUE CROSS BLUE SHIELD
1568834893OtherNPI