Healthcare Provider Details

I. General information

NPI: 1568971026
Provider Name (Legal Business Name): BRANDON JAMES FORDHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E BROAD ST
SAINT PAULS NC
28384-1610
US

IV. Provider business mailing address

60 COMMERCE PLAZA CIR
PEMBROKE NC
28372-7386
US

V. Phone/Fax

Practice location:
  • Phone: 910-241-3042
  • Fax: 910-241-3462
Mailing address:
  • Phone: 910-521-2900
  • Fax: 910-775-9165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07597
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: