Provider Demographics
NPI:1558611822
Name:SMITH, BRANDON MICHAEL (PA C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:SMITH
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-944-8910
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:16528 E DESMET CT
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3522
Practice Address - Country:US
Practice Address - Phone:509-944-8910
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA176068363AM0700X
IDPA1449363AM0700X
WAPA61179237363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical