Provider Demographics
NPI:1053789719
Name:MCNICKLE, BRANDON ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROBERT
Last Name:MCNICKLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:201 BLUEBIRD DR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2301
Practice Address - Country:US
Practice Address - Phone:615-859-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant