Healthcare Provider Details

I. General information

NPI: 1518940584
Provider Name (Legal Business Name): STEPHEN COLSON BRANUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 VAIL AVE SUITE A
CHARLOTTE NC
28207-1219
US

IV. Provider business mailing address

4601 PARK RD STE 300
CHARLOTTE NC
28209-3239
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-2000
  • Fax:
Mailing address:
  • Phone: 704-323-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number480
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number102360
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: