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General NPI Number Information
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NPI Number | 1841427937
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Entity Type | Individual
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Provider Name | JUSTIN MICHAEL BREWER MMS, ATC, PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/16/2009
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Last Update Date | 05/08/2014
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Provider Practice Location Address
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Address Line | 527 MEDICAL PARK DR STE 400
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City | BRIDGEPORT
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State | WV
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Zip | 26330-9010
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Country | US
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Telephone | 681-342-3500
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Fax | 681-342-3507
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Provider Business Mailing Address
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Address Line | 527 MEDICAL PARK DR STE 400
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City | BRIDGEPORT
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State | WV
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Zip | 26330-9010
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Country | US
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Telephone | 681-342-3500
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Fax | 681-342-3507
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110003033
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 01518
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License Number State | WV
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 513
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License Number State | WV
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