Basic Information
| Provider Information | |||||||||
| NPI: | 1770923682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 25477 | ||||||||
| Address2: | FORSYTH EMERGENCY SERVICES P.A. | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271145447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367659328 | ||||||||
| FaxNumber: | 3367685762 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367659328 | ||||||||
| FaxNumber: | 3367685762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04304 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.