Provider Demographics
NPI:1437125408
Name:LEVERENZ, BRENDA L (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:LEVERENZ
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 1:1217 KEARNEY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3571
Mailing Address - Country:US
Mailing Address - Phone:810-982-2095
Mailing Address - Fax:810-982-8513
Practice Address - Street 1:1217 KEARNEY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3571
Practice Address - Country:US
Practice Address - Phone:810-982-2095
Practice Address - Fax:810-982-8513
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00221152OtherPALMETTO RAILROAD MEDICARE
MIG46040114Medicare PIN
P00221152OtherPALMETTO RAILROAD MEDICARE