Provider Demographics
NPI:1497441430
Name:WOOLDRIDGE, BRANDON EDWARD
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:EDWARD
Last Name:WOOLDRIDGE
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 1:1193 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:GOODE
Mailing Address - State:VA
Mailing Address - Zip Code:24556-2708
Mailing Address - Country:US
Mailing Address - Phone:434-401-2196
Mailing Address - Fax:
Practice Address - Street 1:1193 MARKET DR
Practice Address - Street 2:
Practice Address - City:GOODE
Practice Address - State:VA
Practice Address - Zip Code:24556-2708
Practice Address - Country:US
Practice Address - Phone:434-401-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant