Healthcare Provider Details

I. General information

NPI: 1356591382
Provider Name (Legal Business Name): LORI KATHRYN BRICKNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORI KATHRYN EARDLEY PA-C

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N. EAST AVE.
JACKSON MI
49201
US

IV. Provider business mailing address

PO BOX 100
ROYAL OAK MI
48068-0100
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 248-849-3137
  • Fax: 248-849-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005355
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: