Provider Demographics
NPI:1598411928
Name:BRENNAN, RYAN (IDMT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6637
Mailing Address - Country:US
Mailing Address - Phone:810-334-6570
Mailing Address - Fax:
Practice Address - Street 1:2864 WOODRUFF ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28302
Practice Address - Country:US
Practice Address - Phone:910-394-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians