Healthcare Provider Details

I. General information

NPI: 1912459033
Provider Name (Legal Business Name): BRENDAN HOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ORCHARD VILLAS AVE STE 100
APEX NC
27502-4339
US

IV. Provider business mailing address

1545 ORCHARD VILLAS AVE
APEX NC
27502-4338
US

V. Phone/Fax

Practice location:
  • Phone: 919-576-8383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4002
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: