Provider Demographics
NPI:1285157958
Name:MACON, BRANDY LADORA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:LADORA
Last Name:MACON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:BRANDY
Other - Middle Name:MACON
Other - Last Name:EUGENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4414 N FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107-1812
Mailing Address - Country:US
Mailing Address - Phone:314-814-8700
Mailing Address - Fax:314-898-1773
Practice Address - Street 1:4414 N FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-1812
Practice Address - Country:US
Practice Address - Phone:314-814-8700
Practice Address - Fax:314-898-1773
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006152363A00000X
363AM0700X
MO2017025341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical