Provider Demographics
NPI:1952498420
Name:BRANDT, CHARLES PHILLIP (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PHILLIP
Last Name:BRANDT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BLOUNT AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1669
Mailing Address - Country:US
Mailing Address - Phone:865-632-5900
Mailing Address - Fax:865-637-2114
Practice Address - Street 1:101 E BLOUNT AVE STE 800
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1669
Practice Address - Country:US
Practice Address - Phone:865-632-5900
Practice Address - Fax:865-637-2114
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA98363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665072Medicaid
TN3046804OtherBCBSTN
TN3665072Medicare ID - Type UnspecifiedMEDICARE
TN3665072Medicaid