Provider Demographics
NPI:1730101452
Name:BALANON, ANGELA N (PA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:N
Last Name:BALANON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:N
Other - Last Name:BRANIECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 673671
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0001
Mailing Address - Country:US
Mailing Address - Phone:313-745-0770
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-598-2869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601994644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004744OtherLICENSE