Provider Demographics
NPI:1982712345
Name:PIACENTINO, BRANDY (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:PIACENTINO
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 WHETSTONE RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8937
Mailing Address - Country:US
Mailing Address - Phone:740-360-0410
Mailing Address - Fax:
Practice Address - Street 1:1947 HARRINGTON MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-8049
Practice Address - Country:US
Practice Address - Phone:419-520-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2388363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0100162Medicaid
OH0100162Medicaid