Provider Demographics
NPI:1265037741
Name:MADSEN, BRANDON (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MADSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 VICKIE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-2402
Mailing Address - Country:US
Mailing Address - Phone:801-885-4284
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:301-688-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6382424-3102163W00000X
WY47281367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse