=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467009134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADEZHDA KRASIK PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2019
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2891 E MAPLE RD # 102S-102
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 485-249-0852
-----------------------------------------------------
Fax | 248-524-9086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2598 BUCKINGHAM AVE
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-7549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-797-0662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------