Provider Demographics
NPI:1184380784
Name:BRECKENKAMP, MEGAN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICOLE
Last Name:BRECKENKAMP
Suffix:
Gender:F
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 1:4030 WESTMINSTER PL APT F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3921
Mailing Address - Country:US
Mailing Address - Phone:636-744-2461
Mailing Address - Fax:
Practice Address - Street 1:261 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-254-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008590208VP0014X
MO2021043557208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine