Provider Demographics
NPI:1932839347
Name:HANAWAY, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:HANAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ELM CT
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-9242
Mailing Address - Country:US
Mailing Address - Phone:254-231-2941
Mailing Address - Fax:
Practice Address - Street 1:3550 S GENERAL BRUCE DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5138
Practice Address - Country:US
Practice Address - Phone:254-312-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA16531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program