Basic Information
| Provider Information | |||||||||
| NPI: | 1043359706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4864 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712026400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307626 | ||||||||
| FaxNumber: | 3183307648 | ||||||||
| Practice Location | |||||||||
| Address1: | 4864 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712026400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307626 | ||||||||
| FaxNumber: | 3183307648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA.A10437.RX | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1781371 | 05 | LA | MEDICAID |