1295828879 NPI number — KEVIN FRANCIS BRENNAN FNP-C

Table of content: KEVIN FRANCIS BRENNAN FNP-C (NPI 1295828879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295828879 NPI number — KEVIN FRANCIS BRENNAN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNAN
Provider First Name:
KEVIN
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRENNAN
Provider Other First Name:
KEVIN
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1295828879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RED LAKE HOSPITAL
Provider Second Line Business Mailing Address:
PO BOX 497, HIGHWAY 1
Provider Business Mailing Address City Name:
RED LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-679-3912
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 STONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-782-7400
Provider Business Practice Location Address Fax Number:
315-782-7460
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LC1500X , with the licence number:  32 320050 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 807 . This is a "STATE LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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