Provider Demographics
NPI:1063233963
Name:WILLE, BRENDAN CHARLES-MULLIGAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:CHARLES-MULLIGAN
Last Name:WILLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1543
Mailing Address - Country:US
Mailing Address - Phone:248-770-6356
Mailing Address - Fax:
Practice Address - Street 1:139 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1543
Practice Address - Country:US
Practice Address - Phone:248-770-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant