Provider Demographics
NPI:1083621452
Name:BRANNAN, MICHELE D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:BRANNAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:TINGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 MEMORIAL DR STE 220
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-474-1723
Mailing Address - Fax:
Practice Address - Street 1:2 MEMORIAL DR STE 220
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-474-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004005137363A00000X
IL085002124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41456Medicare UPIN