Healthcare Provider Details

I. General information

NPI: 1730575481
Provider Name (Legal Business Name): MARIYA PRIYMAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CADIEUX RD
GROSSE POINTE MI
48230-1507
US

IV. Provider business mailing address

130 TOWN CENTER DR SUITE 203
TROY MI
48084-1744
US

V. Phone/Fax

Practice location:
  • Phone: 313-473-1605
  • Fax: 313-473-1934
Mailing address:
  • Phone: 248-585-8265
  • Fax: 248-585-8266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2015009432
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007438
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: