Healthcare Provider Details

I. General information

NPI: 1104570811
Provider Name (Legal Business Name): KARA MARIE PESOLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47601 GRAND RIVER AVE
NOVI MI
48374-1233
US

IV. Provider business mailing address

3168 SOLUTIONS CTR # 773168
CHICAGO IL
60677-3001
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4311
  • Fax: 248-465-4651
Mailing address:
  • Phone: 248-680-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: