Healthcare Provider Details

I. General information

NPI: 1366203903
Provider Name (Legal Business Name): NICHOLAS BRANDT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 JOHNSON AVE STE 101
SAN LUIS OBISPO CA
93401-4154
US

IV. Provider business mailing address

1941 JOHNSON AVE STE 101
SAN LUIS OBISPO CA
93401-4154
US

V. Phone/Fax

Practice location:
  • Phone: 805-782-8844
  • Fax: 805-549-6985
Mailing address:
  • Phone: 805-782-8844
  • Fax: 805-549-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: