Provider Demographics
NPI:1093949885
Name:BRAND, JEFFREY ALLEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALLEN
Last Name:BRAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1 WICKERSHAM ST
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-9117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WICKERSHAM ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-9117
Practice Address - Country:US
Practice Address - Phone:580-782-3353
Practice Address - Fax:580-782-5103
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1849363AM0700X
COPA.0003313363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200264640AMedicaid
OK1849OtherLICENSE