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General NPI Number Information
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NPI Number | 1003393190
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Entity Type | Individual
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Provider Name | DEVYN PORATH
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Gender | Female
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Dates
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Enumeration Date | 07/23/2018
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Last Update Date | 07/23/2018
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Provider Practice Location Address
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Address Line | 39555 W 10 MILE RD STE 302
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City | NOVI
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State | MI
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Zip | 48375-2950
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Country | US
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Telephone | 248-426-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 15739 SCOTT ST
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City | SOUTHGATE
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State | MI
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Zip | 48195-1323
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Country | US
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Telephone | 734-308-7224
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5315094078
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License Number State | MI
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