Healthcare Provider Details

I. General information

NPI: 1205611308
Provider Name (Legal Business Name): STANIYA MARANGATTIL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 S LINDEN RD # 3A
FLINT MI
48532-3459
US

IV. Provider business mailing address

4837 VINEWOOD DR
STERLING HEIGHTS MI
48314-2935
US

V. Phone/Fax

Practice location:
  • Phone: 810-410-4869
  • Fax:
Mailing address:
  • Phone: 586-804-2748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: