Provider Demographics
NPI:1790158392
Name:BLACKSTON, BRANDY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:
Last Name:BLACKSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:27901 WOODWARD AVE STE 300
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0921
Practice Address - Country:US
Practice Address - Phone:248-545-0070
Practice Address - Fax:248-545-4850
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical