Provider Demographics
NPI:1770923682
Name:BLANK, BRANDON JAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:JAY
Last Name:BLANK
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:P.O. BOX 25477
Mailing Address - Street 2:FORSYTH EMERGENCY SERVICES P.A.
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-5447
Mailing Address - Country:US
Mailing Address - Phone:336-765-9328
Mailing Address - Fax:336-768-5762
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-765-9328
Practice Address - Fax:336-768-5762
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-10-29
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Provider Licenses
StateLicense IDTaxonomies
NC0010-04304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant