Healthcare Provider Details

I. General information

NPI: 1124812458
Provider Name (Legal Business Name): BRENDAN HANSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

4685 FOREST AVE
CINCINNATI OH
45212-3397
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-1111
  • Fax:
Mailing address:
  • Phone: 513-246-1964
  • Fax: 513-852-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010368RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: