Basic Information
| Provider Information | |||||||||
| NPI: | 1518693084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANFALONE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNAP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20360 RAMBLING DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480387507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866252757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HARRINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864938000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2022 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704314956 | MI | N | Nursing Service Providers | Registered Nurse | 367500000X | 4704314956 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.