Provider Demographics
NPI:1093467599
Name:TART, BRANTLEY AUSTIN (PNP-PC)
Entity Type:Individual
Prefix:MR
First Name:BRANTLEY
Middle Name:AUSTIN
Last Name:TART
Suffix:
Gender:M
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7574
Mailing Address - Country:US
Mailing Address - Phone:910-763-2476
Mailing Address - Fax:
Practice Address - Street 1:715 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7574
Practice Address - Country:US
Practice Address - Phone:910-763-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015665208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics