Provider Demographics
NPI:1942799895
Name:PORTEN, BRANDON ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:ROBERT
Last Name:PORTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL
Mailing Address - Street 2:STE 35
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-227-6551
Mailing Address - Fax:
Practice Address - Street 1:2601 CENTENNIAL DR
Practice Address - Street 2:STE 100
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3087
Practice Address - Country:US
Practice Address - Phone:651-777-7414
Practice Address - Fax:651-748-5839
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN66104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty