BRANT MICHAEL BALTHAZOR Physician Assistant License verification

Business Entity

INOPERATIVE

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****12

License Status

INOPERATIVE

Business

First Name

BRANT

Middle

MICHAEL

Last Name

BALTHAZOR

Business Name

BRANT MICHAEL BALTHAZOR

Original Issue Date

07/08/2015

Effective Date

01/15/2020

Expiration Date

03/01/2022

City

KANKAKEE

State

Zip

60901

County

KANKAKEE

Ever Disciplined

LastModifiedDate

01/03/2022