Provider Demographics
NPI:1003513730
Name:TATAR, BRANDON MICHAEL (MSN, APRN, ACCNS-AG)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:TATAR
Suffix:
Gender:M
Credentials:MSN, APRN, ACCNS-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53460 MEADOW VIEW LN
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5841
Mailing Address - Country:US
Mailing Address - Phone:586-854-1108
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-854-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704363198364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care