Provider Demographics
NPI:1184983371
Name:DYER, BRETT AARON
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:AARON
Last Name:DYER
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 1:110 ROANE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2334
Mailing Address - Country:US
Mailing Address - Phone:304-344-0096
Mailing Address - Fax:304-342-4725
Practice Address - Street 1:4605 MACCORKLE AVNEUE, SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-766-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV68352163W00000X
WV88063367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ39833AOtherMEDICARE PTAN
WV3810023357Medicaid