Provider Demographics
NPI:1700011731
Name:SMITH, BREANNA JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:JOY
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:JOY
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5329
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-0329
Mailing Address - Country:US
Mailing Address - Phone:616-364-6700
Mailing Address - Fax:989-401-4245
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-6789
Practice Address - Fax:616-685-3064
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant