Provider Demographics
NPI:1790544534
Name:MICKELSON, BRANDON SHAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:SHAWN
Last Name:MICKELSON
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 1:3030 MONTFORT LOOP
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5235
Mailing Address - Country:US
Mailing Address - Phone:208-251-2630
Mailing Address - Fax:
Practice Address - Street 1:11760 S 700 E STE 112
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6605
Practice Address - Country:US
Practice Address - Phone:801-882-9995
Practice Address - Fax:801-882-9994
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program