Provider Demographics
NPI:1629216999
Name:SHERRY, BRENDAN JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRENDAN
Middle Name:JAMES
Last Name:SHERRY
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:PO BOX 120234
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0104
Mailing Address - Country:US
Mailing Address - Phone:517-712-8296
Mailing Address - Fax:
Practice Address - Street 1:1342 W MAIN ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1923
Practice Address - Country:US
Practice Address - Phone:616-527-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-25
Last Update Date:2009-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant