Healthcare Provider Details

I. General information

NPI: 1639659667
Provider Name (Legal Business Name): BRENAN VEGA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

1871 CLEAR BROOK CT
CHATTANOOGA TN
37421-2784
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-8550
  • Fax:
Mailing address:
  • Phone: 615-852-2379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123198
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number180787
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: