Provider Demographics
NPI:1790544534
Name:MICKELSON, BRANDON SHAWN (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SHAWN
Last Name:MICKELSON
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 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:
Practice Address - Street 1:11760 S 700 E STE 112
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6605
Practice Address - Country:US
Practice Address - Phone:801-882-9995
Practice Address - Fax:801-882-9994
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant