Healthcare Provider Details

I. General information

NPI: 1215960380
Provider Name (Legal Business Name): BRENDAN WRYNN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 VIRGINIA AVE
CONNERSVILLE IN
47331-2833
US

IV. Provider business mailing address

3507 N GRAND AVE APT 31
CONNERSVILLE IN
47331-3475
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-7708
  • Fax:
Mailing address:
  • Phone: 765-827-7708
  • Fax: 765-827-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN293240L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: