Provider Demographics
NPI:1043607369
Name:ANDERSON, BRANDON (AGACNP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12812
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8050 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2478
Practice Address - Country:US
Practice Address - Phone:317-415-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005507A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201292680Medicaid
INP01512410OtherMEDICARE RR PTAN
IN201292680Medicaid