Provider Demographics
NPI:1740509355
Name:BLACK, BRANDON D (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:MASSACHUSETTS ANESTHESIA CORP.
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072
Mailing Address - Country:US
Mailing Address - Phone:646-415-3838
Mailing Address - Fax:
Practice Address - Street 1:255 PLAIN DRIVE
Practice Address - Street 2:C/O MA ANESTHESIA CORP.
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072
Practice Address - Country:US
Practice Address - Phone:617-523-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2263659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered