Healthcare Provider Details

I. General information

NPI: 1407138399
Provider Name (Legal Business Name): DESIRAE DYAN DELBRIDGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4154 W VIENNA RD
CLIO MI
48420-2809
US

IV. Provider business mailing address

225 E 5TH ST SUITE 300
FLINT MI
48502-1641
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-1008
  • Fax:
Mailing address:
  • Phone: 810-406-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601006127
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: