Healthcare Provider Details

I. General information

NPI: 1316676539
Provider Name (Legal Business Name): BRENNA NICOLE EASTMAN EWING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 W 151ST ST
OLATHE KS
66061-5305
US

IV. Provider business mailing address

153 W 151ST ST STE 100
OLATHE KS
66061-5300
US

V. Phone/Fax

Practice location:
  • Phone: 913-764-1125
  • Fax: 913-764-1186
Mailing address:
  • Phone: 913-764-1125
  • Fax: 913-764-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1502825
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: