Provider Demographics
NPI:1508116450
Name:HERMANSEN, BRANDON S (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:S
Last Name:HERMANSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6711038-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT143659OtherPEHP
UT964305OtherWINDSOR HEALTH PLAN MEDICAREEXTRA/STERLING HEALTH PLAN
UTP01132445OtherRAILROAD MEDICARE
UTP01132445OtherRAILROAD MEDICARE