Provider Demographics
NPI:1750498721
Name:BREWER, LARRY ARNOLD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ARNOLD
Last Name:BREWER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 BURLINGAME S.W.
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519
Mailing Address - Country:US
Mailing Address - Phone:616-956-8333
Mailing Address - Fax:616-940-5820
Practice Address - Street 1:2929 BURLINGAME S.W.
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-956-8333
Practice Address - Fax:616-940-5820
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001187Medicaid
MI5601001187Medicaid