Healthcare Provider Details

I. General information

NPI: 1346739224
Provider Name (Legal Business Name): BRIAN JAMES TSACOUMANGOS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2018
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 HANNAH BLVD STE 114
EAST LANSING MI
48823-5380
US

IV. Provider business mailing address

5689 FRANCESCA LN
SHELBY TOWNSHIP MI
48316-5752
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-8080
  • Fax: 517-364-8088
Mailing address:
  • Phone: 586-295-0734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5315090741
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: