Healthcare Provider Details

I. General information

NPI: 1831218734
Provider Name (Legal Business Name): THERESA M WHALEN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44405 WOODWARD
PONTIAC MI
48431
US

IV. Provider business mailing address

38840 EQUESTRIAN S #48102
FARMINGTON HILLS MI
48331-4930
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-3000
  • Fax:
Mailing address:
  • Phone: 734-652-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601002763
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: