Provider Demographics
NPI:1497269583
Name:BRENNA, ETHAN JOSEPH (MSGC)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:JOSEPH
Last Name:BRENNA
Suffix:
Gender:M
Credentials:MSGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4539
Mailing Address - Country:US
Mailing Address - Phone:701-234-2448
Mailing Address - Fax:701-234-7239
Practice Address - Street 1:820 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4539
Practice Address - Country:US
Practice Address - Phone:701-234-2448
Practice Address - Fax:701-234-7239
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty