Healthcare Provider Details

I. General information

NPI: 1710024161
Provider Name (Legal Business Name): ANN C THIBODEAU-ASHFORD PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANN C THIBODEAU PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 N BARLOW RD
HARRISVILLE MI
48740-9607
US

IV. Provider business mailing address

177 N BARLOW RD
HARRISVILLE MI
48740-9607
US

V. Phone/Fax

Practice location:
  • Phone: 989-736-8157
  • Fax: 989-358-3762
Mailing address:
  • Phone: 989-736-8157
  • Fax: 989-358-3762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: