Provider Demographics
NPI:1528404704
Name:RUSSELL, BRENNAN VICTOR (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:VICTOR
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 EMERALD PL STE 201
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5743
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:
Practice Address - Street 1:300 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1111
Practice Address - Country:US
Practice Address - Phone:919-350-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC322367500000X
NC265185163W00000X
PA111111111367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse