Provider Demographics
NPI:1306401260
Name:BISSO, BRANDON BLAKELY (NP)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:BLAKELY
Last Name:BISSO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10545 SUMMER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5084
Mailing Address - Country:US
Mailing Address - Phone:706-631-5247
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-882-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN220792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner