Provider Demographics
NPI:1982999504
Name:BREW, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 MESA RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-6731
Mailing Address - Country:US
Mailing Address - Phone:614-625-6486
Mailing Address - Fax:
Practice Address - Street 1:3120 MIDLAND VALLEY ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6970
Practice Address - Country:US
Practice Address - Phone:614-943-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK209311363LF0000X
OHPN.133673-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse