Provider Demographics
NPI:1366424665
Name:MAZE, BRENT MICHAEL (PAC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:MICHAEL
Last Name:MAZE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 LAPEER
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1208
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:3884 MONITOR ROAD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9298
Practice Address - Country:US
Practice Address - Phone:989-671-2000
Practice Address - Fax:989-671-4000
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
147434OtherGREAT LAKES HEALTH PLAN
MI080G310660OtherBLUE CROSS BLUE SHIELD MI
MI1012083OtherMCLAREN HEALTH PLAN
292OtherCOMMUNITY CHOICE OF MI
MI0G36111-089Medicare PIN
147434OtherGREAT LAKES HEALTH PLAN