Provider Demographics
NPI:1073250429
Name:REAGAN, BRANSON (AUD)
Entity Type:Individual
Prefix:DR
First Name:BRANSON
Middle Name:
Last Name:REAGAN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 1877
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0014
Mailing Address - Country:US
Mailing Address - Phone:315-255-8419
Mailing Address - Fax:
Practice Address - Street 1:USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI
Practice Address - Street 2:1 MISUMI MACHI
Practice Address - City:IWAKUNI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:315-255-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA.02376231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist