Provider Demographics
NPI:1831328137
Name:BRENNER, MICHAEL CHARLES (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:5420 WADE PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4188
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:114 BRADY CT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4554
Practice Address - Country:US
Practice Address - Phone:919-469-1252
Practice Address - Fax:919-469-1373
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-01829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant