Provider Demographics
NPI:1497408173
Name:BRENNAN, MAGEN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MAGEN
Middle Name:LEE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:488 KENNESAW AVE NW STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9409
Mailing Address - Country:US
Mailing Address - Phone:770-427-3075
Mailing Address - Fax:770-427-3261
Practice Address - Street 1:488 KENNESAW AVE NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9409
Practice Address - Country:US
Practice Address - Phone:770-427-3075
Practice Address - Fax:770-427-3261
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10934363A00000X
ALPA2025363A00000X
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant