Provider Demographics
NPI:1205627494
Name:BROSNAN, BRENT JACOB
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JACOB
Last Name:BROSNAN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68982 WILLOW CREEK RD # 536
Mailing Address - Street 2:
Mailing Address - City:HEPPNER
Mailing Address - State:OR
Mailing Address - Zip Code:97836-6258
Mailing Address - Country:US
Mailing Address - Phone:541-676-5125
Mailing Address - Fax:541-676-5186
Practice Address - Street 1:68982 WILLOW CREEK RD # 536
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836-6258
Practice Address - Country:US
Practice Address - Phone:541-676-5125
Practice Address - Fax:541-676-5186
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist