Healthcare Provider Details

I. General information

NPI: 1487220539
Provider Name (Legal Business Name): MICHAEL ALLEN BRANDLE JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2021
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY STREET SUITE 7C SHAPIRO BUILDING
BOSTON MA
02118
US

IV. Provider business mailing address

725 ALBANY ST STE 7C
BOSTON MA
02118-3549
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8992
  • Fax: 617-638-8979
Mailing address:
  • Phone: 617-638-8992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8810
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: