Provider Demographics
NPI:1194134783
Name:CLANCY, BRENDAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:CLANCY
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 1:2800 BLUE RIDGE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6477
Mailing Address - Country:US
Mailing Address - Phone:919-784-7110
Mailing Address - Fax:
Practice Address - Street 1:2800 BLUE RIDGE RD STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-784-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017848363A00000X
NC0010-08302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017848OtherNYS PHYSICIAN ASSISTANT LICENSE