Basic Information
| Provider Information | |||||||||
| NPI: | 1336576750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEVES | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | JOSHUA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 14050 TOWN LOOP BLVD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328376190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078526650 | ||||||||
| FaxNumber: | 4078526035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107503 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.