Provider Demographics
NPI:1598362311
Name:MEDEIROS, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 BECKWITH ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-1851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 PRESIDENT AVE RM 304
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5923
Practice Address - Country:US
Practice Address - Phone:508-235-6427
Practice Address - Fax:508-235-6654
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02417363L00000X
MARN2293550363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAPRN02417OtherAPRN LICENSE
MARN2293550OtherAPRN LICENSE