Basic Information
| Provider Information | |||||||||
| NPI: | 1457808644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAR | ||||||||
| FirstName: | MANDEEP | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | 2694888972 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 MICHIGAN AVE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747224921 | ||||||||
| FaxNumber: | 5747390520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2016 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704347087 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71006503A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000001051082 | 01 | IN | ANTHEM | OTHER | 201391250 | 05 | IN | MEDICAID | P01727211 | 01 | IN | RAILROAD MEDICARE | OTHER |