Provider Demographics
NPI:1053897215
Name:FERGUSON, BRETT ANTHONY
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:ANTHONY
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0019
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:8033 W FLORISSANT AVE STE A
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:MO
Practice Address - Zip Code:63136-1412
Practice Address - Country:US
Practice Address - Phone:314-888-0971
Practice Address - Fax:314-408-7062
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009032382363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health