Healthcare Provider Details

I. General information

NPI: 1699060160
Provider Name (Legal Business Name): BRANDON TRAGESER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 W HIGHWAY 98
PANAMA CITY FL
32401-1170
US

IV. Provider business mailing address

PO BOX 2699
PENSACOLA FL
32513-2699
US

V. Phone/Fax

Practice location:
  • Phone: 850-914-7060
  • Fax: 850-914-7065
Mailing address:
  • Phone: 850-475-4686
  • Fax: 850-475-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9105986
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105986
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: