Provider Demographics
NPI:1720765969
Name:TULLY, BRENDEN G (PA)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:G
Last Name:TULLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CASTLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44403-8603
Mailing Address - Country:US
Mailing Address - Phone:330-413-7913
Mailing Address - Fax:
Practice Address - Street 1:2420 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4954
Practice Address - Country:US
Practice Address - Phone:440-997-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008422RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant