Provider Demographics
NPI:1730348145
Name:RYSEWYK, BRENT JOSEPH (IDC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JOSEPH
Last Name:RYSEWYK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AIRPORT ROAD
Mailing Address - Street 2:LENOIR MEMORIAL HOSPITAL
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501
Mailing Address - Country:US
Mailing Address - Phone:252-522-7954
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant