Provider Demographics
NPI:1376634998
Name:EGAN, BRENT H (NP)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:H
Last Name:EGAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 W MAPLE LOOP DR
Mailing Address - Street 2:STE 125
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5620
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:STE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001045363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner