| Provider / Organization | NPI | Date Certified |
|---|---|---|
| BRANT MICHAEL BALTHAZOR | 1548640774 | 2024-01-07 |
Brant M Balthazor [M] graduated in 2015 and primarily specializes in Physician Assistant.
Brant Michael Balthazor is registered with the National Plan and Provider Enumeration System and has been issued an National Provider Identifier (NPI) of 1548640774. Registration indicates Brant Michael Balthazor is a provider of access to adult/geriatric primary care providers services with a specialization in Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers) Access to Adult/Geriatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers)
| PECOS ID | 5496063208 |
| Registration | PART-B:Y DME:Y HHA:Y PMD:Y |
| Entity Type | Individual |
| Provider Name | Brant Michael Balthazor MS, PA-C |
| Practice Office Address | 2124 KOHLER MEMORIAL DR SHEBOYGAN, WI US |
| Practice Office Telephone | 8838217246 |
| Mailing Address | 3624 COUNTY ROAD I SAUKVILLE, WI 530801446 US |
| Business Telephone | 7349453484 |
| Address | City / State | Phone / Fax |
|---|---|---|
| 375 N Wall St Ste P530 | Kankakee, IL 609013483 | 8159327200 / 8159357874 |
| Direct Messaging Address [] | [email protected] | Direct |
| FHIR URL [] | https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/ |
| Code | Practice | License No State |
|---|---|---|
| 363A00000X | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers | 085005469
IL |
| 363A00000X PRIMARY | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers | 4424-023
WI |
| 100100767 | MEDICAID | WI |