Basic Information
| Provider Information | |||||||||
| NPI: | 1023445277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1325 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407021325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065268131 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 TRILLIUM WAY | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065264070 | ||||||||
| FaxNumber: | 6065264072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1826 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100268870 | 05 | KY | MEDICAID | P01404879 | 01 | KY | RR MEDICARE | OTHER |