Provider Demographics
NPI:1639319536
Name:GALE, BRANDON R (PA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:R
Last Name:GALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3294
Mailing Address - Country:US
Mailing Address - Phone:309-691-1400
Mailing Address - Fax:309-689-7094
Practice Address - Street 1:6000 N ALLEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3294
Practice Address - Country:US
Practice Address - Phone:309-691-1400
Practice Address - Fax:309-693-3154
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003438Medicaid
IL565970001Medicare PIN
IL085003438Medicaid