Healthcare Provider Details

I. General information

NPI: 1326514613
Provider Name (Legal Business Name): BRANDON TIMOTHY PACE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GARRETT AVE
LA PLATA MD
20646-5960
US

IV. Provider business mailing address

21692 POTOMAC VIEW DR
LEONARDTOWN MD
20650-2134
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4444
  • Fax:
Mailing address:
  • Phone: 212-920-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR233658
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: