Basic Information
| Provider Information | |||||||||
| NPI: | 1366424665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZE | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 LAPEER | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486071208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897596464 | ||||||||
| FaxNumber: | 9893998233 | ||||||||
| Practice Location | |||||||||
| Address1: | 3884 MONITOR ROAD | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487069298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896712000 | ||||||||
| FaxNumber: | 9896714000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601004410 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 147434 | 01 | GREAT LAKES HEALTH PLAN | OTHER | 080G310660 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 1012083 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 292 | 01 | COMMUNITY CHOICE OF MI | OTHER |