Healthcare Provider Details

I. General information

NPI: 1598541922
Provider Name (Legal Business Name): BRENDON MATELSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 S M 30
WEST BRANCH MI
48661-9312
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-2000
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-3660
  • Fax:
Mailing address:
  • Phone: 844-832-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012025
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: