Provider Demographics
NPI:1932706744
Name:COBURN, BRANDON LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:COBURN
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 1:107 STAUNTON DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-5604
Mailing Address - Country:US
Mailing Address - Phone:304-269-2022
Mailing Address - Fax:304-269-2037
Practice Address - Street 1:107 STAUNTON DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-5604
Practice Address - Country:US
Practice Address - Phone:304-269-2022
Practice Address - Fax:304-269-2037
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV363A00000X
DEC5-0011853363A00000X
MDC0008580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant