Provider Demographics
NPI:1033476288
Name:BRENTZ, DAVID A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:BRENTZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-0607
Mailing Address - Country:US
Mailing Address - Phone:601-947-3161
Mailing Address - Fax:601-947-9206
Practice Address - Street 1:859 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6603
Practice Address - Country:US
Practice Address - Phone:601-947-3161
Practice Address - Fax:601-947-9206
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR889843367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered