Basic Information
Provider Information
NPI: 1255807038
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DECOSTA
FirstName: BRANDON
MiddleName: RYAN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 219 PANORAMA DR
Address2:  
City: BENICIA
State: CA
PostalCode: 945101513
CountryCode: US
TelephoneNumber: 7072081005
FaxNumber:  
Practice Location
Address1: 1652 W TEXAS ST
Address2:  
City: FAIRFIELD
State: CA
PostalCode: 945336066
CountryCode: US
TelephoneNumber: 9254622281
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/18/2018
LastUpdateDate: 10/18/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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