Provider Demographics
NPI:1275103855
Name:BAILEY, BRENDAN P
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:P
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 W 26TH PL
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-7018
Mailing Address - Country:US
Mailing Address - Phone:417-499-5218
Mailing Address - Fax:
Practice Address - Street 1:4311 W 26TH PL
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-7018
Practice Address - Country:US
Practice Address - Phone:417-499-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK390200000XOtherORGANIZED HEALTH EDUCATION/TRAINING PROGRAM