Healthcare Provider Details

I. General information

NPI: 1144876780
Provider Name (Legal Business Name): BRANDON THOMAS STOUT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W RIVER WOODS PKWY
GLENDALE WI
53212-1081
US

IV. Provider business mailing address

3872 E VAN NORMAN AVE
CUDAHY WI
53110-1228
US

V. Phone/Fax

Practice location:
  • Phone: 414-961-6800
  • Fax:
Mailing address:
  • Phone: 414-617-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number220296-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128013
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: