Provider Demographics
NPI:1326514613
Name:PACE, BRANDON TIMOTHY (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:TIMOTHY
Last Name:PACE
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 1:21692 POTOMAC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2134
Mailing Address - Country:US
Mailing Address - Phone:212-920-9559
Mailing Address - Fax:
Practice Address - Street 1:5 GARRETT AVE
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5960
Practice Address - Country:US
Practice Address - Phone:301-609-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR233658367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered