=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578082525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON TODD WHANN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2017
-----------------------------------------------------
Last Update Date | 09/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6501 COYLE AVE
-----------------------------------------------------
City | CARMICHAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95608-0306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-571-0429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2352 PINTURO WAY
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-5247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------