Healthcare Provider Details

I. General information

NPI: 1073867172
Provider Name (Legal Business Name): BRIAN UPPER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E MICHIGAN AVE STE 400
LANSING MI
48912-1806
US

IV. Provider business mailing address

405 W GREENLAWN AVE
LANSING MI
48910-2898
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-9650
  • Fax: 517-364-9605
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006451
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: