Provider Demographics
NPI:1699488627
Name:CRISWELL, BRENNEN
Entity type:Individual
Prefix:
First Name:BRENNEN
Middle Name:
Last Name:CRISWELL
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 1:1448 10TH AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-691-6381
Mailing Address - Fax:304-691-8591
Practice Address - Street 1:1600 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3657
Practice Address - Country:US
Practice Address - Phone:304-691-1100
Practice Address - Fax:304-691-1153
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant