Healthcare Provider Details

I. General information

NPI: 1487234886
Provider Name (Legal Business Name): BRETT ALLEN DURBIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 FERGUSON DR
CINCINNATI OH
45245-5136
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 513-232-2663
  • Fax: 859-817-7848
Mailing address:
  • Phone: 859-301-2663
  • Fax: 859-817-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006814RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: