Provider Demographics
NPI:1386617504
Name:O'HAIR, BRENDA M (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:O'HAIR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LOU
Other - Last Name:O'HAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3065
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1755 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3109
Practice Address - Country:US
Practice Address - Phone:863-904-6201
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102155363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291558800Medicaid
FLU0614ZMedicare PIN
P88787Medicare UPIN