Healthcare Provider Details

I. General information

NPI: 1033473350
Provider Name (Legal Business Name): ALYSON R BOKSHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 JACKSON RD STE 100
ANN ARBOR MI
48103-1889
US

IV. Provider business mailing address

4350 JACKSON RD STE 100
ANN ARBOR MI
48103-1889
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-9344
  • Fax: 734-971-2303
Mailing address:
  • Phone: 734-971-9344
  • Fax: 734-971-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2012020961
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301111606
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: