Healthcare Provider Details

I. General information

NPI: 1679972798
Provider Name (Legal Business Name): JEFFREY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BIRCH ST
GLENROCK WY
82637-0786
US

IV. Provider business mailing address

1118 COTTONWOOD
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 307-436-9206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPT 606
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: