Healthcare Provider Details

I. General information

NPI: 1932182193
Provider Name (Legal Business Name): TODD BRANER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3305
US

IV. Provider business mailing address

1630 E HERNDON AVE
FRESNO CA
93720-3305
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-5200
  • Fax: 559-256-5376
Mailing address:
  • Phone: 559-256-5200
  • Fax: 559-256-5376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: