Provider Demographics
NPI:1417905241
Name:DESPER, BRANDI L (NP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:DESPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 CLEMENT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1563
Mailing Address - Country:US
Mailing Address - Phone:415-221-4810
Mailing Address - Fax:
Practice Address - Street 1:3701 PEBBLE PLACE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-7725
Practice Address - Country:US
Practice Address - Phone:812-454-0508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001387A207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000323458OtherBCBS CLOVIS MANLEY MD LLC
IN211850Medicare PIN
INP00062619OtherRAILROAD MEDICARE
IN000000372388OtherBCBS MEC LOCATIONS
INDA5417OtherRR MEDICARE
Q00009Medicare UPIN
IN4628860001Medicare NSC
IN131250LLMedicare ID - Type UnspecifiedMEC - LAWNDALE LOCATION
IN131290LLMedicare ID - Type UnspecifiedMEC 1ST AVE LOCATION
IN211850BMedicare PIN