Provider Demographics
NPI:1023015682
Name:BRANDT, ROBERTA WRIGHT (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:WRIGHT
Last Name:BRANDT
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:FULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:517-783-2728
Practice Address - Street 1:544 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1013
Practice Address - Country:US
Practice Address - Phone:517-780-0838
Practice Address - Fax:517-780-0689
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP95573Medicare UPIN
MI0N79450Medicare ID - Type Unspecified