Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 2020033532 | MO |
NPI | 1023472511 |
---|---|
Provider Name | Joshua Brandon |
First Address | Springfield, MO 65808-9007 |
Second Address | Springfield, MO 65807-7310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2016 |
Last Update Date | 22/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200072741 | (05) | MO |