Provider Demographics
NPI:1356814040
Name:BRANTLEY, ELIZABETH BARBARA (PA)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:BARBARA
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1208 WATSON AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5010
Mailing Address - Country:US
Mailing Address - Phone:859-816-4379
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-3472
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2019-01-06
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019004090363A00000X
MDC0008113363A00000X
NC0010-12558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220068521Medicaid