Provider Demographics
NPI:1003117318
Name:SIMMONS, BRANDON L
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:A
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4735 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-9286
Mailing Address - Country:US
Mailing Address - Phone:805-238-1276
Mailing Address - Fax:
Practice Address - Street 1:4735 BEACON RD
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-9286
Practice Address - Country:US
Practice Address - Phone:805-238-1276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3106146M00000X
CAD1361389172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No172A00000XOther Service ProvidersDriver