Healthcare Provider Details

I. General information

NPI: 1558671263
Provider Name (Legal Business Name): AUTUMN S GRATZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 S SAGINAW ST SUITE 1400
FLINT MI
48507-2645
US

IV. Provider business mailing address

23664 COPPERWOOD DR E
SOUTH LYON MI
48178-8274
US

V. Phone/Fax

Practice location:
  • Phone: 810-391-0662
  • Fax: 810-239-8330
Mailing address:
  • Phone: 724-272-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005900
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: