BRANT MICHAEL BALTHAZOR Physician Assistant License verification

Business Entity

INACTIVE

License Type

Physician Assistant

Description

LICENSED PHYSICIAN ASSISTANT

License Number

085005469

License Status

INACTIVE

Business

First Name

BRANT

Middle

MICHAEL

Last Name

BALTHAZOR

Business Name

BRANT MICHAEL BALTHAZOR

Original Issue Date

05/27/2015

Effective Date

01/15/2020

Expiration Date

03/01/2022

City

SAUKVILLE

State

Zip

53080

Ever Disciplined

LastModifiedDate

01/06/2022