=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073317566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS RYAN BRANDSER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2025
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4777 E GALBRAITH RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45236-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-686-5446
-----------------------------------------------------
Fax | 513-686-6868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 E 6TH ST STE 209
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27101-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-207-0775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------