Provider Demographics
NPI:1144578998
Name:BRANCH, NICHOLAS M (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:M
Last Name:BRANCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 PINE GROVE AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3500
Mailing Address - Country:US
Mailing Address - Phone:810-985-4300
Mailing Address - Fax:810-985-9320
Practice Address - Street 1:1231 PINE GROVE AVE STE 1A
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3500
Practice Address - Country:US
Practice Address - Phone:810-985-4300
Practice Address - Fax:810-985-9320
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X, 363AS0400X
MI5315080694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical