Provider Demographics
NPI:1699060160
Name:TRAGESER, BRANDON (PA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:TRAGESER
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:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4686
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:4121 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1170
Practice Address - Country:US
Practice Address - Phone:850-914-7060
Practice Address - Fax:850-914-7065
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9105986363A00000X
FLPA9105986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021361300Medicaid