Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 4301085852 | MI |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 4301085852 | MI |
NPI | 1316093529 |
---|---|
Provider Name | Dr. Gwen Marie Brandt |
First Address | Grand Rapids, MI 49503 |
Second Address | Grand Rapids, MI 49503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2007 |
Last Update Date | 14/06/2011 |