Provider Demographics
NPI:1114665148
Name:BOGARD, BRANDON (APRN)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BOGARD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-868-7272
Mailing Address - Fax:
Practice Address - Street 1:1840 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4716
Practice Address - Country:US
Practice Address - Phone:321-360-5577
Practice Address - Fax:321-806-2087
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPG869OtherMEDICARE HF
FL114654100Medicaid