Basic Information
| Provider Information | |||||||||
| NPI: | 1114519873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | BRENTON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALL | ||||||||
| OtherFirstName: | BRENT | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192090278 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197314268 | ||||||||
| FaxNumber: | 4192090645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2021 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0028349 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.