Healthcare Provider Details

I. General information

NPI: 1134225550
Provider Name (Legal Business Name): EUGENE A PRESTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 HOLLYWOOD RD
SAINT JOSEPH MI
49085-8510
US

IV. Provider business mailing address

17511 HEPLER ST
SOUTH BEND IN
46635-1831
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-2552
  • Fax: 269-428-2943
Mailing address:
  • Phone: 574-276-6248
  • Fax: 269-428-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002633
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: