Provider Demographics
NPI:1023031762
Name:SWANSON, BRIAN DOUGLAS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 E US HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-6819
Mailing Address - Country:US
Mailing Address - Phone:573-346-3700
Mailing Address - Fax:573-346-3307
Practice Address - Street 1:226 E US HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-6819
Practice Address - Country:US
Practice Address - Phone:573-346-3700
Practice Address - Fax:573-346-3307
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004036186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ40418Medicare UPIN
MO000097183Medicare ID - Type Unspecified