Provider Demographics
NPI:1649479031
Name:SMITH, BRANDON GREGORY (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:GREGORY
Last Name:SMITH
Suffix:
Gender:M
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 1:2222N NEVADA AVE 4007
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6863
Mailing Address - Country:US
Mailing Address - Phone:719-776-8500
Mailing Address - Fax:719-634-1448
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 700
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-635-7172
Practice Address - Fax:719-444-3771
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-2496363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96130857Medicaid
CO262938YLB8Medicare PIN