Provider Demographics
NPI:1588202949
Name:PAYNE, BREANNA MARIE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 HORSE THIEF LN
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3106
Mailing Address - Country:US
Mailing Address - Phone:970-759-1669
Mailing Address - Fax:
Practice Address - Street 1:373 HORSE THIEF LN
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3106
Practice Address - Country:US
Practice Address - Phone:970-759-1669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant