Provider Demographics
NPI:1710464151
Name:BROWN, BRAD WESLEY (FNP)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:WESLEY
Last Name:BROWN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 E INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3748
Mailing Address - Country:US
Mailing Address - Phone:417-866-8209
Mailing Address - Fax:
Practice Address - Street 1:2021 E INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3748
Practice Address - Country:US
Practice Address - Phone:417-866-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018015761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily