Provider Demographics
NPI:1558789784
Name:BRANDON, NICOLE ANJA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANJA
Last Name:BRANDON
Suffix:
Gender:F
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 1:16250 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5775 BLUE LAGOON DRIVE
Practice Address - Street 2:SUITE 190
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:305-442-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107836363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant