Healthcare Provider Details

I. General information

NPI: 1962045666
Provider Name (Legal Business Name): BRANDON MACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 02/18/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 YORBA LINDA BLVD
FULLERTON CA
92831-1699
US

IV. Provider business mailing address

2575 YORBA LINDA BLVD
FULLERTON CA
92831-1699
US

V. Phone/Fax

Practice location:
  • Phone: 714-449-7400
  • Fax:
Mailing address:
  • Phone: 714-449-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: