Provider Demographics
NPI:1790878304
Name:BRENNER, DAVID LAWRENCE (RPA-C, MS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:BRENNER
Suffix:
Gender:M
Credentials:RPA-C, MS
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 602484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2484
Mailing Address - Country:US
Mailing Address - Phone:910-815-5830
Mailing Address - Fax:910-815-5698
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-815-5830
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY008246363AM0700X
NC0010-02442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102441Medicaid
NC1790878304Medicaid
NC2762452Medicare PIN