Healthcare Provider Details

I. General information

NPI: 1063233963
Provider Name (Legal Business Name): BRENDAN CHARLES-MULLIGAN WILLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S LAPEER RD STE 100
LAKE ORION MI
48360-1468
US

IV. Provider business mailing address

25010 30 MILE RD
LENOX MI
48050-1501
US

V. Phone/Fax

Practice location:
  • Phone: 248-693-3551
  • Fax: 248-693-4643
Mailing address:
  • Phone: 248-770-6356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012822
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: