Provider Demographics
NPI:1750736179
Name:KLITSCH, BRENDAN SCHANEL (PA)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:SCHANEL
Last Name:KLITSCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 N TRADE ST
Practice Address - Street 2:STE 1100
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1728
Practice Address - Country:US
Practice Address - Phone:704-512-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750736179Medicaid
SC2673PAMedicaid
NCNCT510DMedicare PIN
NCNCT510EMedicare PIN
NCNCT510BMedicare PIN
NCNCT510CMedicare PIN
NCNCT510AMedicare PIN