Provider Demographics
NPI:1063455061
Name:BRANNON, PATRICK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:BRANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 RESERVOIR AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4448
Mailing Address - Country:US
Mailing Address - Phone:401-946-1810
Mailing Address - Fax:401-946-4364
Practice Address - Street 1:725 RESERVOIR AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4448
Practice Address - Country:US
Practice Address - Phone:401-946-1810
Practice Address - Fax:401-946-4364
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI5343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR9000518Medicaid
PR9000518Medicaid