Provider Demographics
NPI:1255855292
Name:NEIDERT, BRANDON (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:NEIDERT
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2614
Mailing Address - Country:US
Mailing Address - Phone:330-489-1000
Mailing Address - Fax:
Practice Address - Street 1:1320 MERCY DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2614
Practice Address - Country:US
Practice Address - Phone:330-489-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021415363LA2100X
OH362722163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse