Provider Demographics
NPI:1568077808
Name:DAMRON, BREANNA LARAE (PA-C)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LARAE
Last Name:DAMRON
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 1:1404 S CALUMET DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41183-9614
Mailing Address - Country:US
Mailing Address - Phone:606-547-5595
Mailing Address - Fax:
Practice Address - Street 1:ENVISION PHYSICIAN SERVICES
Practice Address - Street 2:1805 27TH ST
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662
Practice Address - Country:US
Practice Address - Phone:740-356-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.007373RX363AM0700X
KYTC031363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical