Provider Demographics
NPI:1750387668
Name:BACHMANN, BRENDA GAYLE (PA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:GAYLE
Last Name:BACHMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-5414
Mailing Address - Country:US
Mailing Address - Phone:574-522-7203
Mailing Address - Fax:574-522-7405
Practice Address - Street 1:640 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-5414
Practice Address - Country:US
Practice Address - Phone:574-522-7203
Practice Address - Fax:574-522-7405
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000514A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000329042OtherBLUE CROSS/BLUE SHIELD
INP00134721OtherRAILROAD MEDICARE
INP53368Medicare UPIN
IN216110AMedicare ID - Type Unspecified