Provider Demographics
NPI:1164784088
Name:PENIX, BRANDON (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:PENIX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 E BROADWAY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-5934
Mailing Address - Country:US
Mailing Address - Phone:509-350-4785
Mailing Address - Fax:509-380-9591
Practice Address - Street 1:821 E BROADWAY AVE STE 1
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5934
Practice Address - Country:US
Practice Address - Phone:509-350-4785
Practice Address - Fax:509-380-9591
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP611150652083P0901X, 2083P0901X
NE1143208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA460177OtherLABOR AND INDUSTRIES PROVIDER NUMBER