Provider Demographics
NPI:1942392287
Name:BLANTON, BRANDON D (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:D
Last Name:BLANTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 15TH ST NW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1620
Mailing Address - Country:US
Mailing Address - Phone:276-679-8890
Mailing Address - Fax:276-679-9740
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-679-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA073553367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100062940Medicaid
VA1942392287Medicaid
VA1942392287Medicaid
VA00X674N27Medicare PIN