1568077808 NPI number — BREANNA LARAE DAMRON PA-C

Table of content: BREANNA LARAE DAMRON PA-C (NPI 1568077808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568077808 NPI number — BREANNA LARAE DAMRON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAMRON
Provider First Name:
BREANNA
Provider Middle Name:
LARAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568077808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1404 S CALUMET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORTHINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41183-9614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-547-5595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ENVISION PHYSICIAN SERVICES
Provider Second Line Business Practice Location Address:
1805 27TH ST
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-356-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 50.007373RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: TC031 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: TC031 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: TC031 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)