Provider Demographics
NPI:1518191618
Name:HISE, BRENNA (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENNA
Middle Name:
Last Name:HISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BRENNA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:338 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6207
Mailing Address - Country:US
Mailing Address - Phone:208-336-0895
Mailing Address - Fax:
Practice Address - Street 1:338 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98935207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine