Healthcare Provider Details

I. General information

NPI: 1356876718
Provider Name (Legal Business Name): JOHN BRENNAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 11/30/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-4619
  • Fax: 877-768-6140
Mailing address:
  • Phone: 951-343-4619
  • Fax: 877-768-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number749914
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA95001107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: