Provider Demographics
NPI:1124544036
Name:GURDEN, BRETT D (PA-C)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:D
Last Name:GURDEN
Suffix:
Gender:M
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 1:818 W KING ST STE 101
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2117
Mailing Address - Country:US
Mailing Address - Phone:989-725-8171
Mailing Address - Fax:989-723-1257
Practice Address - Street 1:818 W KING ST STE 101
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2117
Practice Address - Country:US
Practice Address - Phone:989-725-8171
Practice Address - Fax:989-723-1257
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002351A363A00000X
MI5601008627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124544036Medicaid