Healthcare Provider Details

I. General information

NPI: 1699487512
Provider Name (Legal Business Name): BRANDON MICHAEL HOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

7100 COON ROCK RD
ARENA WI
53503-9306
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-7002
  • Fax:
Mailing address:
  • Phone: 608-588-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number242459-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14646-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: