Provider Demographics
NPI:1952317083
Name:CORWIN, BRYAN W (PAC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:CORWIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 S 144TH ST
Mailing Address - Street 2:STE 212
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0852
Practice Address - Street 1:2725 S 144TH ST
Practice Address - Street 2:STE 212
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0852
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38624OtherBCBS OF NEBRASKA
NE38624OtherBCBS OF NEBRASKA
P10794Medicare UPIN