Healthcare Provider Details

I. General information

NPI: 1841913456
Provider Name (Legal Business Name): MIRA RHAE LUKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRA RHAE VONDERHEIDE PA-C

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2300
  • Fax: 586-228-6201
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013766
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9270
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: