Healthcare Provider Details

I. General information

NPI: 1730364142
Provider Name (Legal Business Name): NICHOLAS BRENNY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 MOUNTAIN VIEW DR STE 300
COLCHESTER VT
05446-5988
US

IV. Provider business mailing address

354 MOUNTAIN VIEW DR STE 300
COLCHESTER VT
05446-5988
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-0192
  • Fax: 802-860-4919
Mailing address:
  • Phone: 802-864-0192
  • Fax: 802-860-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number055-0030894
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9104082
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030894
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: