Healthcare Provider Details

I. General information

NPI: 1093763088
Provider Name (Legal Business Name): DENESE S IRISH P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E WILLIAMS ST
OWOSSO MI
48867-2360
US

IV. Provider business mailing address

113 E WILLIAMS ST
OWOSSO MI
48867-2360
US

V. Phone/Fax

Practice location:
  • Phone: 989-725-6101
  • Fax: 989-723-3601
Mailing address:
  • Phone: 989-725-6101
  • Fax: 989-723-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003942
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: