=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962731513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. BRIAN HOWARD EARL KREBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2009
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 JOEL DR
-----------------------------------------------------
City | FORT CAMPBELL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42223-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-801-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2179 CHESTER HARRIS RD
-----------------------------------------------------
City | WOODLAWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37191-8235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-801-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------