Provider Demographics
NPI:1205557600
Name:BURANDT, MICHAELA
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:BURANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JOHN DEERE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6812
Mailing Address - Country:US
Mailing Address - Phone:309-779-4400
Mailing Address - Fax:309-779-4420
Practice Address - Street 1:600 JOHN DEERE RD STE 301
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6812
Practice Address - Country:US
Practice Address - Phone:309-779-4400
Practice Address - Fax:309-779-4420
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-010106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant