Provider Demographics
NPI:1316777428
Name:PELAEZ, BRANDON HUGO (PA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:HUGO
Last Name:PELAEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3550
Mailing Address - Country:US
Mailing Address - Phone:516-833-5505
Mailing Address - Fax:
Practice Address - Street 1:5505 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3550
Practice Address - Country:US
Practice Address - Phone:516-833-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032043-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant