Basic Information
| Provider Information | |||||||||
| NPI: | 1215205463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | BUCKLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4838 E BASELINE RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809812400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 N HIGLEY RD | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852341604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809812400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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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 | 163W00000X | R188877-1 | MN | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN148370 | AZ | N | Nursing Service Providers | Registered Nurse | 367500000X | CRNA0825 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.