Provider Demographics
NPI:1184018558
Name:BRANDON, THOMAS JESSE (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JESSE
Last Name:BRANDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25373 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1425
Mailing Address - Country:US
Mailing Address - Phone:586-436-4469
Mailing Address - Fax:
Practice Address - Street 1:10101 RENNER BLVD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-9752
Practice Address - Country:US
Practice Address - Phone:800-873-8845
Practice Address - Fax:913-859-6887
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704243187363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology