Provider Demographics
NPI:1649201336
Name:BRENNEMAN, GERALD EDWIN (PAC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:EDWIN
Last Name:BRENNEMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 819
Mailing Address - Street 2:25 NORTH JOHNSON ST.
Mailing Address - City:COATS
Mailing Address - State:NC
Mailing Address - Zip Code:27521-0819
Mailing Address - Country:US
Mailing Address - Phone:910-897-6423
Mailing Address - Fax:910-897-2540
Practice Address - Street 1:COATS MEDICAL CLINIC
Practice Address - Street 2:25 NORTH JOHNSON ST.
Practice Address - City:COATS
Practice Address - State:NC
Practice Address - Zip Code:27521
Practice Address - Country:US
Practice Address - Phone:910-897-6423
Practice Address - Fax:910-897-2540
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101469OtherSTATE LICENSE NUMBER