Provider Demographics
NPI:1780060988
Name:BATHRICK, BRANDON CHARLES (RN-BSN)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:CHARLES
Last Name:BATHRICK
Suffix:
Gender:M
Credentials:RN-BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1869
Mailing Address - Country:US
Mailing Address - Phone:607-425-1786
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1869
Practice Address - Country:US
Practice Address - Phone:607-425-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA153131146N00000X
NY603096163W00000X
PARN597760163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY603096OtherNEW YORK STATE DEPARTMENT OF HEALTH
PARN597760OtherPENNSYLVANIA DEPARTMENT OF HEALTH