Provider Demographics
NPI:1164938007
Name:EMRY, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:EMRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:260-458-5831
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1673
Practice Address - Country:US
Practice Address - Phone:260-425-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28217961A163W00000X
IN71007787A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse