Provider Demographics
NPI:1932570397
Name:MITCHELL, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MITCHELL
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 1:1101 W EAGLE DR STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3721
Mailing Address - Country:US
Mailing Address - Phone:940-627-1770
Mailing Address - Fax:940-627-2233
Practice Address - Street 1:1101 W EAGLE DR STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3721
Practice Address - Country:US
Practice Address - Phone:940-627-1770
Practice Address - Fax:940-624-2233
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGOtherBCBSTX