Provider Demographics
NPI:1225460298
Name:EGNER, BRANDON JAIME (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAIME
Last Name:EGNER
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 1:500 W BROADWAY ST STE 320
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4003
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-2791
Practice Address - Street 1:500 W BROADWAY ST STE 320
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-2791
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056269363AM0700X
MT66952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALICENSEOtherMA056269