Healthcare Provider Details

I. General information

NPI: 1548970734
Provider Name (Legal Business Name): BRANDON VIXAMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 S JOG RD STE 103
BOYNTON BEACH FL
33437-3532
US

IV. Provider business mailing address

10075 S JOG RD STE 103
BOYNTON BEACH FL
33437-3532
US

V. Phone/Fax

Practice location:
  • Phone: 561-903-0289
  • Fax:
Mailing address:
  • Phone:
  • 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: