Healthcare Provider Details

I. General information

NPI: 1588663835
Provider Name (Legal Business Name): TED A. BRANSTETTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2332
  • Fax:
Mailing address:
  • Phone: 509-663-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10003588
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10707
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003588
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: