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General NPI Number Information
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NPI Number | 1275872376
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Entity Type | Individual
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Provider Name | DIMA SPRAGUE
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Gender | Female
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Dates
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Enumeration Date | 02/08/2013
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Last Update Date | 02/21/2017
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Provider Practice Location Address
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Address Line | 28800 RYAN RD
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City | WARREN
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State | MI
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Zip | 48092-4272
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Country | US
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Telephone | 586-577-9444
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Fax |
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Provider Business Mailing Address
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Address Line | 6924 APPOLINE ST UPPER LEVEL
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City | DEARBORN
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State | MI
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Zip | 48126-1989
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Country | US
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Telephone |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601006517
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 5601006517
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License Number State | MI
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