Basic Information
| Provider Information | |||||||||
| NPI: | 1275295925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | ELLIS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 MANHATTAN BLVD APT 1217 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410747517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192061479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10506 MONTGOMERY RD STE 209 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002250953 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2021 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50.007107RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.