Provider Demographics
NPI:1043589054
Name:PATTON, BRANDI NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:PATTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PARK PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3127
Mailing Address - Country:US
Mailing Address - Phone:662-222-2273
Mailing Address - Fax:662-269-6346
Practice Address - Street 1:180 PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3127
Practice Address - Country:US
Practice Address - Phone:662-222-2273
Practice Address - Fax:662-269-6346
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00160363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02394OtherMEDICARE