Healthcare Provider Details

I. General information

NPI: 1760194450
Provider Name (Legal Business Name): ALYSSA AUSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

IV. Provider business mailing address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1431
  • Fax:
Mailing address:
  • Phone: 517-205-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number2000052659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: