Healthcare Provider Details

I. General information

NPI: 1285960708
Provider Name (Legal Business Name): BRANDY JANE MANCHESTER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W 7TH AVE SUITE 450
SPOKANE WA
99204-2332
US

IV. Provider business mailing address

400 E 5TH AVE
SPOKANE WA
99204-2332
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-2960
  • Fax: 509-462-3142
Mailing address:
  • Phone: 509-342-3759
  • Fax: 509-342-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60118161
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: