=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750049565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. BRANDON MARQUIS CRAYON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2021
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3419 COUNTY ROAD 20
-----------------------------------------------------
City | STANLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14561-9522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-905-8516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 ANGELUS DR
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14622-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-694-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 341139-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------