Basic Information
| Provider Information | |||||||||
| NPI: | 1558328369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROTHERS | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1026 W 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551023007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512411000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1026 W 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551023007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512411000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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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 | 363A00000X | 9724 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 050464500 | 05 | MN | MEDICAID |