Provider Demographics
NPI:1609591551
Name:O'NEILL, BRENDEN
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:
Last Name:O'NEILL
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 1:3711 S SR 27 HWY APT J302
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6186
Mailing Address - Country:US
Mailing Address - Phone:208-590-9251
Mailing Address - Fax:
Practice Address - Street 1:5901 N LIDGERWOOD ST STE 218
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1122
Practice Address - Country:US
Practice Address - Phone:509-464-6208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1199432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant