Basic Information
| Provider Information | |||||||||
| NPI: | 1184979676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWITT | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 NORTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553712172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633897740 | ||||||||
| FaxNumber: | 7633896595 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2012 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11169 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 1766 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.