Basic Information
| Provider Information | |||||||||
| NPI: | 1902279474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELDER | ||||||||
| FirstName: | BRENDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10828 OLD PRESCOTT RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232383529 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 SPRING ST | ||||||||
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| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534051667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626874011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 108356 | WI | N | Nursing Service Providers | Registered Nurse | 367500000X | 164539-30 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.