Provider Demographics
NPI:1093815144
Name:WHARTON, BRENDA JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JO
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:616-459-0044
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004126363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382285194OtherTAX ID
MI0N86230001Medicare ID - Type Unspecified
MIQ09057Medicare UPIN