Healthcare Provider Details

I. General information

NPI: 1750387668
Provider Name (Legal Business Name): BRENDA GAYLE BACHMANN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 INDUSTRIAL PKWY
ELKHART IN
46516-5414
US

IV. Provider business mailing address

640 INDUSTRIAL PKWY
ELKHART IN
46516-5414
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-7203
  • Fax: 574-522-7405
Mailing address:
  • Phone: 574-522-7203
  • Fax: 574-522-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000514A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: