Provider Demographics
NPI:1205001922
Name:BRANNON, JAMES KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KEVIN
Last Name:BRANNON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-0729
Mailing Address - Country:US
Mailing Address - Phone:334-793-2663
Mailing Address - Fax:334-836-2248
Practice Address - Street 1:1500 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4754
Practice Address - Country:US
Practice Address - Phone:334-793-2663
Practice Address - Fax:334-836-2248
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-582363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003184448 A & BMedicaid
AL192973Medicaid
AL193179Medicaid
AL511-84985OtherBCBS OF ALABAMA - RCC
AL511-84987OtherBCBS OF ALABAMA - HW
AL102I975864Medicare PIN