Provider Demographics
NPI:1629070297
Name:BRANDT, WADE JASON (CNP)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:JASON
Last Name:BRANDT
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:315-359-2123
Mailing Address - Fax:315-359-2167
Practice Address - Street 1:1200 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-359-2123
Practice Address - Fax:315-359-2167
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR038406ANDCP000642363L00000X
OR201802902NP-PP363LF0000X
NY344384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500704675Medicaid