Provider Demographics
NPI:1295722270
Name:BRONSON, KAREN L (PA-C)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:BRONSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:L
Other - Last Name:VANDAELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-8865
Mailing Address - Fax:248-344-2350
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:313-916-8865
Practice Address - Fax:248-344-2350
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001431363AM0700X, 363A00000X
MI5601003196363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00864076OtherRRMC
OH000000587469OtherANTHEM
OHP00647130OtherRRMC
OHP00647130OtherRRMC
OH000000587469OtherANTHEM
OHP00647130OtherRRMC