Provider Demographics
NPI:1376950204
Name:GOLDSMITH, BRANDON (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GOLDSMITH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5452
Mailing Address - Fax:601-815-3322
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5452
Practice Address - Fax:601-815-3322
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04586367Medicaid
AL178296Medicaid
MSP01454795OtherRAILROAD MEDICARE PTAN
MSP01454795OtherRAILROAD MEDICARE PTAN