Healthcare Provider Details

I. General information

NPI: 1144538216
Provider Name (Legal Business Name): ALYSSA KATE GIRARDIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21031 MICHIGAN AVE
DEARBORN MI
48124-2339
US

IV. Provider business mailing address

3545 LINDEN ST
DEARBORN MI
48124-4260
US

V. Phone/Fax

Practice location:
  • Phone: 313-277-6700
  • Fax: 313-277-2483
Mailing address:
  • Phone: 313-730-9146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601005880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: