Provider Demographics
NPI:1194839985
Name:BRANNON, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRANNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7102
Mailing Address - Country:US
Mailing Address - Phone:270-441-4343
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR STE 301
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4343
Practice Address - Fax:270-441-4344
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1300704Medicare ID - Type UnspecifiedMEDICARE
KYS57501Medicare UPIN