Basic Information
| Provider Information | |||||||||
| NPI: | 1457318040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRECKE | ||||||||
| FirstName: | STEFAN | ||||||||
| MiddleName: | FRIEDRICH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7068 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237070068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863508 | ||||||||
| FaxNumber: | 7576860541 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEADE PKWY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234344259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7579349409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
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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 | 363A00000X | 0110840823 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970009887 | 01 | VA | RAILROAD MEDICARE | OTHER | 8922951 | 05 | VA | MEDICAID |