Healthcare Provider Details

I. General information

NPI: 1992301949
Provider Name (Legal Business Name): MARGO AHLSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 01/09/2022
Certification Date: 01/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53375 WHITBY WAY
SHELBY TWP MI
48316-2751
US

IV. Provider business mailing address

53375 WHITBY WAY
SHELBY TWP MI
48316-2751
US

V. Phone/Fax

Practice location:
  • Phone: 586-907-8139
  • Fax:
Mailing address:
  • Phone: 586-907-8139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: