Healthcare Provider Details

I. General information

NPI: 1255411468
Provider Name (Legal Business Name): BRANDI JO DESAVEUR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 W. 5TH AVE.
SPOKANE WA
99204
US

IV. Provider business mailing address

PO BOX 8500 LOCKBOX 7642
PHILADELPHIA PA
19178-7642
US

V. Phone/Fax

Practice location:
  • Phone: 509-455-7844
  • Fax: 509-623-0415
Mailing address:
  • Phone: 813-281-8115
  • Fax: 813-281-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10005083
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: