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General NPI Number Information
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NPI Number | 1699488627
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Entity Type | Individual
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Provider Name | BRENNEN CRISWELL
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Gender | Male
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Dates
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Enumeration Date | 01/04/2023
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Last Update Date | 10/11/2024
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Provider Practice Location Address
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Address Line | 1600 MEDICAL CENTER DRIVE SUITE 1500
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City | HUNTINGTON
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State | WV
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Zip | 25701-3657
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Country | US
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Telephone | 304-691-1100
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Fax | 304-691-1153
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Provider Business Mailing Address
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Address Line | 1448 10TH AVENUE SUITE 304
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City | HUNTINGTON
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State | WV
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Zip | 25701-3579
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Country | US
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Telephone | 304-691-6381
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Fax | 304-691-8591
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2876
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License Number State | WV
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