Provider Demographics
NPI:1790729762
Name:BRANT, BRIAN L (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:BRANT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1452
Mailing Address - Country:US
Mailing Address - Phone:906-483-1000
Mailing Address - Fax:906-483-1122
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1452
Practice Address - Country:US
Practice Address - Phone:906-483-1000
Practice Address - Fax:906-483-1122
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704197904367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI429769910Medicaid
MIS80209Medicare UPIN
MI0N26520003Medicare ID - Type Unspecified