Provider Demographics
NPI:1124783527
Name:CONDIT, BRIAN WILLIAM (RN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:CONDIT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-7973
Mailing Address - Country:US
Mailing Address - Phone:662-397-5291
Mailing Address - Fax:
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4934
Practice Address - Country:US
Practice Address - Phone:662-377-4394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901962367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered