Provider Demographics
NPI:1356846448
Name:DOUGLASS, BRANDON GENE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:GENE
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S APPLE BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-8810
Mailing Address - Country:US
Mailing Address - Phone:509-682-6138
Mailing Address - Fax:
Practice Address - Street 1:110 S APPLE BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-8810
Practice Address - Country:US
Practice Address - Phone:509-682-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29131208600000X
MN66304208600000X
WAMD61445708208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery