Provider Demographics
NPI:1902410749
Name:BREMER, SOPHIE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:BREMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 W ELK AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2883
Mailing Address - Country:US
Mailing Address - Phone:423-543-8124
Mailing Address - Fax:
Practice Address - Street 1:1503 W ELK AVE STE 5
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2883
Practice Address - Country:US
Practice Address - Phone:423-543-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC363A00000X
TN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant