Provider Demographics
NPI:1265900260
Name:BRENNAN, CASEY
Entity type:Individual
Prefix:MR
First Name:CASEY
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9274
Mailing Address - Country:US
Mailing Address - Phone:804-765-5000
Mailing Address - Fax:804-765-5521
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00241176871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily