Provider Demographics
NPI:1154805083
Name:WEBSTER, BRODY A (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRODY
Middle Name:A
Last Name:WEBSTER
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 1:16261 ROSELAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-4929
Mailing Address - Country:US
Mailing Address - Phone:989-277-6060
Mailing Address - Fax:
Practice Address - Street 1:22471 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2353
Practice Address - Country:US
Practice Address - Phone:586-218-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant