Provider Demographics
NPI:1861161689
Name:MANIBOG, BRANDON COLE (FNP-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:COLE
Last Name:MANIBOG
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28576 FOOTHILL WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-3290
Mailing Address - Country:US
Mailing Address - Phone:928-514-9131
Mailing Address - Fax:
Practice Address - Street 1:26910 SIERRA HWY STE D8
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2262
Practice Address - Country:US
Practice Address - Phone:661-210-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018275363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner