Healthcare Provider Details

I. General information

NPI: 1790729762
Provider Name (Legal Business Name): BRIAN L BRANT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR
HANCOCK MI
49930-1452
US

IV. Provider business mailing address

500 CAMPUS DR
HANCOCK MI
49930-1452
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1000
  • Fax: 906-483-1122
Mailing address:
  • Phone: 906-483-1000
  • Fax: 906-483-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704197904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: