Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

1600 BRANDON DR
HEBRON KY
41048-9571
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: