Provider Demographics
NPI:1568025146
Name:CHASE, BRIAN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CHASE
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 HOLLY HILL LN
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6072
Mailing Address - Country:US
Mailing Address - Phone:203-864-5515
Mailing Address - Fax:
Practice Address - Street 1:856 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1221
Practice Address - Country:US
Practice Address - Phone:203-869-5765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8168363L00000X
CT8618363LA2100X
MARN259758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8168OtherNURSE PRACTITIONER
MARN259758OtherNURSE PRACTITIONER