Provider Demographics
NPI:1225808462
Name:HALL, BRENDAN JAMES
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:JAMES
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BURTON DR APT 176
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2630 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2301
Practice Address - Country:US
Practice Address - Phone:907-377-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant