Healthcare Provider Details

I. General information

NPI: 1770055741
Provider Name (Legal Business Name): SHERIDAN BROWN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2019
Last Update Date: 10/22/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N KEENE ST
COLUMBIA MO
65201-6625
US

IV. Provider business mailing address

401 N KEENE ST
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018045083
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: