Provider Demographics
NPI:1790054617
Name:BRAUN, DEANA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:MARIE
Last Name:BRAUN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:MARIE
Other - Last Name:GIRBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGN ST NE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2533
Practice Address - Country:US
Practice Address - Phone:616-267-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM36590073Medicare PIN