Provider Demographics
NPI:1376734921
Name:BRANDON, DARYL ADRIAN
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:ADRIAN
Last Name:BRANDON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DARYL
Other - Middle Name:ADRIAN
Other - Last Name:BRANDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:522 MANILA AVENUE
Mailing Address - Street 2:APT 1
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302
Mailing Address - Country:US
Mailing Address - Phone:201-659-7687
Mailing Address - Fax:
Practice Address - Street 1:522 MANILA AVENUE
Practice Address - Street 2:APT 1
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:201-993-9654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146808164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02229023Medicaid