Basic Information
| Provider Information | |||||||||
| NPI: | 1720472624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 2ND FL, SUITE C203 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088520600 | ||||||||
| FaxNumber: | 5083683143 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2015 | ||||||||
| LastUpdateDate: | 03/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA5318 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.