Provider Demographics
NPI:1609840511
Name:BRANDT, LEE BRIAN JR (PA)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:BRIAN
Last Name:BRANDT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:BRIAN
Other - Last Name:BRANDT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:5665 NEW NORTHSIDE DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:404-645-7564
Mailing Address - Fax:
Practice Address - Street 1:4900 IVEY RD NW
Practice Address - Street 2:SUITE 1826
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4001
Practice Address - Country:US
Practice Address - Phone:770-975-9077
Practice Address - Fax:770-790-4964
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003438363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000704EMedicaid
GA100000704CMedicaid
GA100000704DMedicaid
P08134Medicare UPIN
GA100000704DMedicaid