Provider Demographics
NPI:1871871673
Name:BLACK, BRANDON (OPA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9301 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0806
Mailing Address - Country:US
Mailing Address - Phone:214-220-2468
Mailing Address - Fax:214-397-1551
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-220-2468
Practice Address - Fax:214-397-1551
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant