Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 32 320050 | NY |
NPI | 1295828879 |
---|---|
Provider Name | Kevin Francis Brennan |
First Address | Red Lake, MN 56671 |
Second Address | Watertown, NY 13601 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 30/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
807 | STATE LICENSE (01) | AK |