Healthcare Provider Details

I. General information

NPI: 1659215077
Provider Name (Legal Business Name): BRENDEN PLANCON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

400 N MCCLURG CT APT 3101
CHICAGO IL
60611-4385
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1600
  • Fax:
Mailing address:
  • Phone: 248-703-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005335A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: