Provider Demographics
NPI:1124785233
Name:FLANNERY, BRENNON (PA-C)
Entity type:Individual
Prefix:
First Name:BRENNON
Middle Name:
Last Name:FLANNERY
Suffix:
Gender:M
Credentials:PA-C
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:801-475-3494
Practice Address - Street 1:3860 JACKSON AVE STE 2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1979
Practice Address - Country:US
Practice Address - Phone:801-627-0515
Practice Address - Fax:801-627-0517
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14084913-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty