Provider Demographics
NPI:1023445277
Name:BRANDON, AMANDA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BRANDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:2 TRILLIUM WAY
Practice Address - Street 2:SUITE 306
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8490
Practice Address - Country:US
Practice Address - Phone:606-526-4070
Practice Address - Fax:606-526-4072
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100268870Medicaid
KYP01404879OtherRR MEDICARE
KY7100268870Medicaid