Provider Demographics
NPI:1255411468
Name:DESAVEUR, BRANDI JO (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:JO
Last Name:DESAVEUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8500 LOCKBOX 7642
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8115
Mailing Address - Fax:813-281-8656
Practice Address - Street 1:911 W. 5TH AVE.
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-455-7844
Practice Address - Fax:509-623-0415
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10005083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0234704OtherL&I
WAP00613585OtherRR MEDICARE
WA80768780OtherID MEDICAID
WA0234704OtherCRIME VICTIMS
WA8799DEOtherASURIS
WAG8873514Medicare Oscar/Certification