Provider Demographics
NPI:1700778446
Name:FORMOZA, BRANDON JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:FORMOZA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SOBER ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NY
Mailing Address - Zip Code:13667-4147
Mailing Address - Country:US
Mailing Address - Phone:315-663-7791
Mailing Address - Fax:
Practice Address - Street 1:50 LEROY ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1786
Practice Address - Country:US
Practice Address - Phone:585-236-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant