Provider Demographics
NPI:1568401875
Name:FORD, BRANT (PA)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4550
Mailing Address - Fax:315-464-6250
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-4550
Practice Address - Fax:315-464-6250
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02799773Medicaid
NYP00424698OtherRAILROAD MEDICARE
NYP00424698OtherRAILROAD MEDICARE
NYPA1427Medicare PIN