Provider Demographics
NPI:1104438662
Name:TALLEY, BRETT ALEXANDER (PA-S)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:ALEXANDER
Last Name:TALLEY
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4203
Mailing Address - Country:US
Mailing Address - Phone:616-848-5953
Mailing Address - Fax:
Practice Address - Street 1:1819 CAREW ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4705
Practice Address - Country:US
Practice Address - Phone:260-702-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program