Healthcare Provider Details

I. General information

NPI: 1871896555
Provider Name (Legal Business Name): BRANDON LEE MONDFRANS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 08/11/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 N MAIN ST
MONROE OH
45050-1236
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 513-461-2273
  • Fax:
Mailing address:
  • Phone: 210-539-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14381
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007424RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: