Basic Information
| Provider Information | |||||||||
| NPI: | 1295828879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRENNAN | ||||||||
| OtherFirstName: | KEVIN | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | RED LAKE HOSPITAL | ||||||||
| Address2: | PO BOX 497, HIGHWAY 1 | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 218 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827400 | ||||||||
| FaxNumber: | 3157827460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC1500X | 32 320050 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 807 | 01 | AK | STATE LICENSE | OTHER |