Provider Demographics
NPI:1528829520
Name:MOCK, BRANDON THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:THOMAS
Last Name:MOCK
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 1:521 S TUMBLEWEED RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4631
Mailing Address - Country:US
Mailing Address - Phone:714-616-4862
Mailing Address - Fax:
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-651-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant