Provider Demographics
NPI:1629524574
Name:NOTZ, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NOTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 SE OAK RIDGE DR APT A
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-9290
Mailing Address - Country:US
Mailing Address - Phone:949-292-5513
Mailing Address - Fax:
Practice Address - Street 1:509 SE OAK RIDGE DR.
Practice Address - Street 2:UNIT A
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075
Practice Address - Country:US
Practice Address - Phone:949-292-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023128163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse