Provider Demographics
NPI:1598790719
Name:BREWTON, MICHAEL SHANE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:BREWTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 NE STALLINGS DR
Mailing Address - Street 2:SUITE110
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1249
Mailing Address - Country:US
Mailing Address - Phone:936-569-9443
Mailing Address - Fax:936-560-5667
Practice Address - Street 1:4800 NE STALLINGS DR
Practice Address - Street 2:SUITE110
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1249
Practice Address - Country:US
Practice Address - Phone:936-569-9443
Practice Address - Fax:936-560-5667
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX701994367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D3093Medicare PIN