Provider Demographics
NPI:1861491706
Name:HERTEL, BRIAN E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:E
Last Name:HERTEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 E VIRGO PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-5898
Mailing Address - Country:US
Mailing Address - Phone:480-229-7651
Mailing Address - Fax:
Practice Address - Street 1:4424 E VIRGO PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-5898
Practice Address - Country:US
Practice Address - Phone:480-229-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3065363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ886872Medicaid
AZ886872Medicaid
AZ85022Medicare ID - Type Unspecified