Healthcare Provider Details

I. General information

NPI: 1609214600
Provider Name (Legal Business Name): EVE J. KOMOSA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N. 10561 GRAND VIEW LANE ASPIRUS GRAND VIEW
IRONWOOD MI
49938
US

IV. Provider business mailing address

3821 TULANE AVE
MADISON WI
53714-2954
US

V. Phone/Fax

Practice location:
  • Phone: 906-932-1500
  • Fax:
Mailing address:
  • Phone: 608-630-1522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006694
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: