Basic Information
| Provider Information | |||||||||
| NPI: | 1225404619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
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| Credential: | CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | EVMS MEDICAL GROUP | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 FAIRFAX AVE | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 0024164094 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1225404619 | 01 | VA | OPTIMA HEALTH | OTHER | 1225404619 | 05 | VA | MEDICAID | 1225404619 | 01 | VA | USA MANAGED CARE | OTHER | 1225404619 | 01 | VA | VIRGINIA PREMIER HEALTH PLAN | OTHER | 1225404619 | 05 | NC | MEDICAID | -002 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1225404619 | 01 | VA | MULTIPLAN | OTHER |