Healthcare Provider Details

I. General information

NPI: 1629988134
Provider Name (Legal Business Name): SIDRA SINAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 MICHIGAN AVE
DEARBORN MI
48126-3574
US

IV. Provider business mailing address

7085 TRAILWAY CT
WEST BLOOMFIELD MI
48322-4564
US

V. Phone/Fax

Practice location:
  • Phone: 313-582-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601014290
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: