Healthcare Provider Details

I. General information

NPI: 1770234056
Provider Name (Legal Business Name): IRINA PAPUSHA AGPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31500 W 13 MILE RD STE 100
FARMINGTON HILLS MI
48334-2172
US

IV. Provider business mailing address

31500 W 13 MILE RD STE 100
FARMINGTON HILLS MI
48334-2172
US

V. Phone/Fax

Practice location:
  • Phone: 248-509-4070
  • Fax: 248-509-4080
Mailing address:
  • Phone: 248-509-4070
  • Fax: 248-509-4080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG12210043
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: