Healthcare Provider Details

I. General information

NPI: 1992748750
Provider Name (Legal Business Name): BRENDA S BRAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N STATE ST STE A
HARRISVILLE MI
48740-9255
US

IV. Provider business mailing address

PO BOX 655
ALPENA MI
49707-0655
US

V. Phone/Fax

Practice location:
  • Phone: 989-724-5655
  • Fax: 989-358-3730
Mailing address:
  • Phone: 989-736-9815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003785
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: