Provider Demographics
NPI:1427643592
Name:PETERSON, BRANDON JOSEPH
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JOSEPH
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 CLEVELAND AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7182
Mailing Address - Country:US
Mailing Address - Phone:239-936-6778
Mailing Address - Fax:
Practice Address - Street 1:19831 ADAMS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4863
Practice Address - Country:US
Practice Address - Phone:630-386-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114114363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical