Healthcare Provider Details

I. General information

NPI: 1730622101
Provider Name (Legal Business Name): COLLEEN MICHELLE GWOZDZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W HIGHLAND RD SUITE 210
HIGHLAND MI
48357-4573
US

IV. Provider business mailing address

210 W HIGHLAND RD SUITE 210
HIGHLAND MI
48357-4573
US

V. Phone/Fax

Practice location:
  • Phone: 248-887-5333
  • Fax:
Mailing address:
  • Phone: 248-887-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008022
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: