Provider Demographics
NPI:1891994786
Name:CANTRELL, BRANDON (PA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CANTRELL
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 1:3708 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2404
Mailing Address - Country:US
Mailing Address - Phone:478-745-4206
Mailing Address - Fax:
Practice Address - Street 1:3708 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2404
Practice Address - Country:US
Practice Address - Phone:478-745-4206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA265457125AMedicaid
GA1580OtherSTATE BOARD OF MEDICAL EX
P00447610OtherMEDICARE RAILROAD PTAN
0357410001Medicare NSC
GA1580OtherSTATE BOARD OF MEDICAL EX