Provider Demographics
NPI:1790736064
Name:EMBRY, BRANDY L (PA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:L
Last Name:EMBRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:L
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:794 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-4074
Practice Address - Country:US
Practice Address - Phone:336-904-2317
Practice Address - Fax:336-443-6030
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02176363A00000X
AZ2097363AM0700X
NC0010-02176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
105014Medicare ID - Type Unspecified
AZP31590Medicare UPIN