Healthcare Provider Details

I. General information

NPI: 1104379601
Provider Name (Legal Business Name): SUSAN WOSIK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 E 12 MILE RD STE 100
WARREN MI
48093-3487
US

IV. Provider business mailing address

26850 PROVIDENCE PKWY STE 350
NOVI MI
48374-1261
US

V. Phone/Fax

Practice location:
  • Phone: 248-662-4110
  • Fax: 248-662-4120
Mailing address:
  • Phone: 248-662-4110
  • Fax: 248-662-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007965
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: