Provider Demographics
NPI:1598891491
Name:BRANDAO, STEPHEN MICHAEL JR (NP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:BRANDAO
Suffix:JR
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 1:1500 LINE AVENUE
Mailing Address - Street 2:STE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:STE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-629-5555
Practice Address - Fax:318-629-5556
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN074738363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B103Medicare PIN
LAP96253Medicare PIN
LA4C777B103Medicare ID - Type Unspecified
LA4C777B103Medicare PIN