Healthcare Provider Details

I. General information

NPI: 1346994746
Provider Name (Legal Business Name): ANDRIA LAILA JANSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDRIA LAILA ZAIDAN

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 10TH ST
PORT HURON MI
48060-5205
US

IV. Provider business mailing address

1225 10TH ST
PORT HURON MI
48060-5205
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-6200
  • Fax:
Mailing address:
  • Phone: 810-987-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: