Provider Demographics
NPI:1508201880
Name:STILSON, BRANDON J (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:J
Last Name:STILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:786 W PIONEER BLVD STE A
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8862
Practice Address - Country:US
Practice Address - Phone:702-345-5000
Practice Address - Fax:702-345-2000
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0057179207Q00000X
390200000X
NV1508201880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20972OtherSTATE LICENSE
CO57175047Medicaid
NV1508201880Medicaid