Provider Demographics
NPI:1609041714
Name:CUSTODIA, BRETT PEYTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:PEYTON
Last Name:CUSTODIA
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 1:14262 TYLER ST
Mailing Address - Street 2:#10
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1584
Mailing Address - Country:US
Mailing Address - Phone:818-741-9129
Mailing Address - Fax:
Practice Address - Street 1:13652 CANTARA ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5423
Practice Address - Country:US
Practice Address - Phone:818-375-2448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3542367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered