Healthcare Provider Details

I. General information

NPI: 1902443047
Provider Name (Legal Business Name): BRAD VAMPLEW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31157 WOODWARD AVE
ROYAL OAK MI
48073-0996
US

IV. Provider business mailing address

13716 LEROY ST
SOUTHGATE MI
48195-3112
US

V. Phone/Fax

Practice location:
  • Phone: 248-336-0123
  • Fax:
Mailing address:
  • Phone: 734-341-1671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601009537
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: