Healthcare Provider Details

I. General information

NPI: 1790278778
Provider Name (Legal Business Name): AMANDA PUTRUS KEJBOU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA PUTRUS PA-C

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15606 SOUTHFIELD RD
ALLEN PARK MI
48101-2513
US

IV. Provider business mailing address

37000 GRAND RIVER AVE STE 310
FARMINGTON HILLS MI
48335-2868
US

V. Phone/Fax

Practice location:
  • Phone: 313-771-5274
  • Fax: 313-771-5256
Mailing address:
  • Phone: 248-536-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008688
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: