Basic Information
| Provider Information | |||||||||
| NPI: | 1710427075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | TREA | ||||||||
| MiddleName: | ANN | ||||||||
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| OtherLastName: | MCNEMAR | ||||||||
| OtherFirstName: | TREA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 860 E BROAD STREET | ||||||||
| Address2: | SUITE I | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440356542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403238515 | ||||||||
| FaxNumber: | 4403237900 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403238515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2017 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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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 | 367500000X | 259599 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.