Provider Demographics
NPI:1992748750
Name:BRAY, BRENDA S (PA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:BRAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-0655
Mailing Address - Country:US
Mailing Address - Phone:989-736-9815
Mailing Address - Fax:
Practice Address - Street 1:205 N STATE ST STE A
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9255
Practice Address - Country:US
Practice Address - Phone:989-724-5655
Practice Address - Fax:989-358-3730
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP65646Medicare UPIN
MIZ16001028Medicare PIN