Provider Demographics
NPI:1851126098
Name:MUNNA, BRANDON 5166287972 (PA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:5166287972
Last Name:MUNNA
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 1:7642 PARK LN S
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1030
Mailing Address - Country:US
Mailing Address - Phone:347-425-5316
Mailing Address - Fax:
Practice Address - Street 1:611 NORTHERN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5208
Practice Address - Country:US
Practice Address - Phone:516-723-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant