Provider Demographics
NPI:1891779732
Name:FENN, BRIAN (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FENN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2183
Mailing Address - Country:US
Mailing Address - Phone:508-746-2000
Mailing Address - Fax:
Practice Address - Street 1:275 SANDWICH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:508-746-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN174475367500000X
NH062441-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0810500Medicaid
NH3134668Medicaid
KY74382060Medicaid
000000179713OtherANTHEM BLUE SHIELD
IN200419580Medicaid
IN200419580Medicaid