Provider Demographics
NPI:1780453191
Name:BIRD, BRETT (NP)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:BIRD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21360 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0053
Mailing Address - Country:US
Mailing Address - Phone:949-292-0334
Mailing Address - Fax:
Practice Address - Street 1:12740 HESPERIA RD STE B
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8306
Practice Address - Country:US
Practice Address - Phone:760-998-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028522363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology