Provider Demographics
NPI:1639659667
Name:VEGA, BRENAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENAN
Middle Name:
Last Name:VEGA
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 1:1871 CLEAR BROOK CT
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2784
Mailing Address - Country:US
Mailing Address - Phone:615-852-2379
Mailing Address - Fax:
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-495-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN123198367500000X
TN180787163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse