Provider Demographics
NPI:1841427937
Name:BREWER, JUSTIN MICHAEL (MMS, ATC, PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:BREWER
Suffix:
Gender:M
Credentials:MMS, ATC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3500
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:527 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9010
Practice Address - Country:US
Practice Address - Phone:681-342-3500
Practice Address - Fax:681-342-3507
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003033363AM0700X
WV01518363AS0400X
WV513363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA37501OtherMEDICARE PTAN