Provider Demographics
NPI:1245431493
Name:CRAFT, BRANDON J (NP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:CRAFT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 FLOWOOD DR
Mailing Address - Street 2:STE. 402
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9303
Mailing Address - Country:US
Mailing Address - Phone:601-936-3100
Mailing Address - Fax:601-936-3130
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:601-262-1009
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR862029207P00000X, 363LA2100X
MS862029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351237Medicaid
MS06672579Medicaid
MS06672579Medicaid