Provider Demographics
NPI:1073063392
Name:BRANNICK, ELIZABETH A (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:BRANNICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1840
Mailing Address - Country:US
Mailing Address - Phone:517-339-2100
Mailing Address - Fax:
Practice Address - Street 1:1881 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1840
Practice Address - Country:US
Practice Address - Phone:517-339-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111012363A00000X
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100013700Medicaid
FLJM891ZOtherMEDICARE