Healthcare Provider Details

I. General information

NPI: 1992553226
Provider Name (Legal Business Name): BRANDON GUEVARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 FLOYD AVE
ROCKY MOUNT VA
24151-1318
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-483-5277
  • Fax: 540-489-6459
Mailing address:
  • Phone: 540-224-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011776
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: