Healthcare Provider Details

I. General information

NPI: 1831433358
Provider Name (Legal Business Name): NATHAN S BREZOVIC ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6797
US

IV. Provider business mailing address

1800 E PARK AVE
STATE COLLEGE PA
16803-6797
US

V. Phone/Fax

Practice location:
  • Phone: 814-278-4818
  • Fax: 814-234-6150
Mailing address:
  • Phone: 814-278-4818
  • Fax: 814-234-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP022985
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP022985
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: