Provider Demographics
NPI:1629436407
Name:BRENNAN, MICHAEL LAWRENCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:BRENNAN
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 1:6200 N HAGGERTY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1532
Mailing Address - Country:US
Mailing Address - Phone:734-526-8860
Mailing Address - Fax:
Practice Address - Street 1:6200 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3605
Practice Address - Country:US
Practice Address - Phone:734-526-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant