Provider Demographics
NPI:1114519873
Name:HALL, BRENTON M (CNP)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:M
Last Name:HALL
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:M
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1098
Practice Address - Country:US
Practice Address - Phone:419-731-4268
Practice Address - Fax:419-209-0645
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner