Provider Demographics
NPI:1801813787
Name:BRANDENBURG, GREGORY H (ARNP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:BRANDENBURG
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-1302
Mailing Address - Country:US
Mailing Address - Phone:270-877-6672
Mailing Address - Fax:270-877-6679
Practice Address - Street 1:101 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1302
Practice Address - Country:US
Practice Address - Phone:270-877-6672
Practice Address - Fax:270-877-6679
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3370P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP21697Medicare UPIN
KY00208002Medicare ID - Type Unspecified