Basic Information
| Provider Information | |||||||||
| NPI: | 1750498721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | ARNOLD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 BURLINGAME S.W. | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169568333 | ||||||||
| FaxNumber: | 6169405820 | ||||||||
| Practice Location | |||||||||
| Address1: | 2929 BURLINGAME S.W. | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169568333 | ||||||||
| FaxNumber: | 6169405820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601001187 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5601001187 | 05 | MI | MEDICAID |