Provider Demographics
NPI:1629315460
Name:BRANNEN, JACOB DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:BRANNEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 BRAMBLETON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3658
Mailing Address - Country:US
Mailing Address - Phone:540-725-7800
Mailing Address - Fax:540-989-6752
Practice Address - Street 1:3707 BRAMBLETON AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:540-989-6752
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant