Provider Demographics
NPI:1649715434
Name:HARTHAN, BRANDON RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:RICHARD
Last Name:HARTHAN
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 1:1490 DOUGLAS DR
Mailing Address - Street 2:LINGLE HALL 118, MC 6620
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4332
Mailing Address - Country:US
Mailing Address - Phone:618-453-4163
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5798
Practice Address - Country:US
Practice Address - Phone:504-899-3496
Practice Address - Fax:504-896-9849
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960041932255A2300X
LA333701363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer