Healthcare Provider Details

I. General information

NPI: 1285687053
Provider Name (Legal Business Name): GRETCHEN I. BRANNON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 S MASON MONTGOMERY RD
MASON OH
45040-3706
US

IV. Provider business mailing address

4600 WESLEY AVE N
CINCINNATI OH
45212-2298
US

V. Phone/Fax

Practice location:
  • Phone: 513-246-7000
  • Fax: 513-202-6355
Mailing address:
  • Phone: 513-246-7800
  • Fax: 513-246-7852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.001892
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: