Healthcare Provider Details

I. General information

NPI: 1184979676
Provider Name (Legal Business Name): BRIAN CHARLES DEWITT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 HWY 70
MINOCQUA WI
54548-9067
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5702
US

V. Phone/Fax

Practice location:
  • Phone: 715-358-1803
  • Fax: 715-358-1316
Mailing address:
  • Phone: 715-387-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1766
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8014
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11169
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: