Provider Demographics
NPI:1760415657
Name:BREWER, KENNETH R (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:BREWER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 YAKIMA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-627-9151
Mailing Address - Fax:
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:STE 110
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-627-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000585213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA480033767OtherMEDICARE RAILROAD
WA480033768OtherMEDICARE RAILROAD
WA8936260OtherSTATE CRIME VICTIMS
WA8936261OtherSTATE CRIME VICTIMS
WA0226419OtherSTATE L&I
WA158900OtherSTATE L&I
WA0158901OtherSTATE L&I
WA8311193Medicaid
WAGAB27483Medicare PIN
WA0226419OtherSTATE L&I
WA158900OtherSTATE L&I
WA8311193Medicaid
WA8936261OtherSTATE CRIME VICTIMS