Healthcare Provider Details

I. General information

NPI: 1720765969
Provider Name (Legal Business Name): BRENDEN G TULLY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

411 CASTLE ROCK RD
BROOKFIELD OH
44403-8603
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2262
  • Fax:
Mailing address:
  • Phone: 330-413-7913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008422RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: