Healthcare Provider Details

I. General information

NPI: 1497704142
Provider Name (Legal Business Name): REGINA SOUTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MEDICAL CENTER DR
CARLETON MI
48117-9461
US

IV. Provider business mailing address

130 MEDICAL CENTER DR
CARLETON MI
48117-9461
US

V. Phone/Fax

Practice location:
  • Phone: 734-654-2169
  • Fax: 734-654-6535
Mailing address:
  • Phone: 734-654-2169
  • Fax: 734-654-6535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601003551
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: