Provider Demographics
NPI:1285687053
Name:BRANNON, GRETCHEN I (PA-C)
Entity Type:Individual
Prefix:MS
First Name:GRETCHEN
Middle Name:I
Last Name:BRANNON
Suffix:
Gender:F
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 1:4600 WESLEY AVE
Mailing Address - Street 2:N
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2298
Mailing Address - Country:US
Mailing Address - Phone:513-246-7800
Mailing Address - Fax:513-246-7852
Practice Address - Street 1:6010 S MASON MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3706
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-202-6355
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBRPA20942Medicare PIN
OHP86530Medicare UPIN