Provider Demographics
NPI:1881889053
Name:LOTTERMAN, BRENT S (PA-C)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:S
Last Name:LOTTERMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 ELECTRIC AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6587
Mailing Address - Country:US
Mailing Address - Phone:810-987-9871
Mailing Address - Fax:
Practice Address - Street 1:2611 ELECTRIC AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-987-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant