Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 10136 | CO |
N | 204E00000X | Oral & Maxillofacial Surgeon | 50000 | CO |
NPI | 1285772301 |
---|---|
Provider Name | Dr. Brandon C Payne |
First Address | Pueblo, CO 81008-2196 |
Second Address | Pueblo, CO 81008-2196 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 18/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33987220 | (05) | CO |