Provider Demographics
NPI:1003895426
Name:BRENNAN, CAROL B (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:B
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 S TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2442
Mailing Address - Country:US
Mailing Address - Phone:480-768-9784
Mailing Address - Fax:480-768-9785
Practice Address - Street 1:475 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5605
Practice Address - Country:US
Practice Address - Phone:480-728-3753
Practice Address - Fax:480-728-3305
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2251363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ909228Medicaid
AZP60146Medicare UPIN
AZ909228Medicaid