Provider Demographics
NPI:1528004959
Name:KOMYKOSKI, BRANDY M (PA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:M
Last Name:KOMYKOSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N 12TH ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1242
Mailing Address - Country:US
Mailing Address - Phone:717-901-8000
Mailing Address - Fax:
Practice Address - Street 1:550 N 12TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:LEMOYNE
Practice Address - State:PA
Practice Address - Zip Code:17043-1242
Practice Address - Country:US
Practice Address - Phone:717-901-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051807363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ29068Medicare UPIN