Provider Demographics
NPI:1356742910
Name:NELSON, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 BREEZE HILL RD
Mailing Address - Street 2:UNIT 251
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-4319
Mailing Address - Country:US
Mailing Address - Phone:858-450-7161
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant