Healthcare Provider Details

I. General information

NPI: 1558988501
Provider Name (Legal Business Name): SERENA HOANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30581 STEPHENSON HWY
MADISON HEIGHTS MI
48071-1610
US

IV. Provider business mailing address

21714 ROOSEVELT AVE
FARMINGTON HILLS MI
48336-4943
US

V. Phone/Fax

Practice location:
  • Phone: 248-589-1770
  • Fax:
Mailing address:
  • Phone: 248-259-4573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009990
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: