Healthcare Provider Details

I. General information

NPI: 1285157958
Provider Name (Legal Business Name): BRANDY LADORA MACON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS BRANDY MACON EUGENE

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 N FLORISSANT AVE
SAINT LOUIS MO
63107-1812
US

IV. Provider business mailing address

4414 N FLORISSANT AVE
SAINT LOUIS MO
63107-1812
US

V. Phone/Fax

Practice location:
  • Phone: 314-814-8700
  • Fax: 314-898-1773
Mailing address:
  • Phone: 314-814-8700
  • Fax: 314-898-1773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006152
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2017025341
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: