Provider Demographics
NPI:1124199088
Name:BRENNAN, CAROLINE BRAGG (PA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:BRAGG
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:ELIZABETH
Other - Last Name:BRAGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1139 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5502
Mailing Address - Country:US
Mailing Address - Phone:912-303-4200
Mailing Address - Fax:912-790-2701
Practice Address - Street 1:1139 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5502
Practice Address - Country:US
Practice Address - Phone:912-303-4200
Practice Address - Fax:912-790-2701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I975559OtherMEDICARE PTAN
GA202I975559OtherMEDICARE PTAN