Provider Demographics
NPI:1922142694
Name:SPAHN, BRANDON MARTIN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:MARTIN
Last Name:SPAHN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2434
Mailing Address - Country:US
Mailing Address - Phone:631-991-3311
Mailing Address - Fax:
Practice Address - Street 1:155 W SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2435
Practice Address - Country:US
Practice Address - Phone:631-991-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029010-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0196271OtherGHI
NY029010OtherVYTRA
NY029010OtherHEALTHCARE PARTHNERS
NY080723000135OtherFIDELIS
NY11817975OtherCAQH
NY029010OtherHIP
NY029010OtherHEALTHCARE PARTHNERS