Healthcare Provider Details

I. General information

NPI: 1932106481
Provider Name (Legal Business Name): ANGELO SO ANTARAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-5609
  • Fax: 734-712-5797
Mailing address:
  • Phone: 734-712-5609
  • Fax: 734-712-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601003519
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: