Individual
MS. BRAELEN DAWN IVICEVICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6560 FANNIN, SCURLOCK TOWER, SUITE 2200, HOUSTON, TX 77030
(281) 737-4560
(281) 737-4561
Mailing address
6560 FANNIN, SCURLOCK TOWER, SUITE 2200, HOUSTON, TX 77030
(281) 737-4560
(281) 737-4561
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
—
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1568834893
NPI
—
01
—
8266NT
BLUE CROSS BLUE SHIELD
TX
Enumeration date
10/26/2015
Last updated
10/07/2021
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