Healthcare Provider Details

I. General information

NPI: 1053893263
Provider Name (Legal Business Name): JESSICA L GELFAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26750 PROVIDENCE PKWY STE 200
NOVI MI
48374-1212
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601008801
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: