Provider Demographics
NPI:1255342556
Name:BRENNAN, SEAN TIMOTHY (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:TIMOTHY
Last Name:BRENNAN
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 1:360 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2700
Mailing Address - Country:US
Mailing Address - Phone:860-688-1311
Mailing Address - Fax:860-687-1319
Practice Address - Street 1:360 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2700
Practice Address - Country:US
Practice Address - Phone:860-688-1311
Practice Address - Fax:860-687-1319
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000964363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970001945Medicare ID - Type Unspecified
P11999Medicare UPIN