Provider Demographics
NPI:1780725820
Name:BRENNER, CATHY JANE (MD)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:JANE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 770510
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0510
Mailing Address - Country:US
Mailing Address - Phone:907-726-1932
Mailing Address - Fax:
Practice Address - Street 1:20217 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8856
Practice Address - Country:US
Practice Address - Phone:907-726-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD4599208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK151742Medicare ID - Type Unspecified
AKE52379Medicare UPIN