Provider Demographics
NPI:1144876780
Name:STOUT, BRANDON THOMAS (CRNA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:THOMAS
Last Name:STOUT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3872 E VAN NORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-1228
Mailing Address - Country:US
Mailing Address - Phone:414-617-8160
Mailing Address - Fax:
Practice Address - Street 1:475 W RIVER WOODS PKWY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1081
Practice Address - Country:US
Practice Address - Phone:414-961-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI220296-30163W00000X
WI128013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse