Provider Demographics
NPI:1871518175
Name:BREWER, MICHAELYN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAELYN
Middle Name:MARIE
Last Name:BREWER
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:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-398-6254
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:1130 N 204TH AVE
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-1849
Practice Address - Country:US
Practice Address - Phone:402-758-5452
Practice Address - Fax:402-758-5398
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098684045Medicare PIN
Q31296Medicare UPIN