Provider Demographics
NPI:1588206627
Name:WARD, BRANDON (NP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WARD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2854
Mailing Address - Country:US
Mailing Address - Phone:336-651-7533
Mailing Address - Fax:
Practice Address - Street 1:306 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2854
Practice Address - Country:US
Practice Address - Phone:336-651-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012336363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962565788Medicaid