Provider Demographics
NPI:1225097710
Name:MOOBERRY, BRANDON T (PAC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:T
Last Name:MOOBERRY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0808
Practice Address - Street 1:2725 S 144TH ST STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5253
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0808
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1190363A00000X
IA001823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ44805Medicare UPIN