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General NPI Number Information
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NPI Number | 1518602655
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Entity Type | Individual
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Provider Name | GINA GRACE EOVALDI PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/03/2022
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Last Update Date | 01/10/2025
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Provider Practice Location Address
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Address Line | 16151 19 MILE RD STE 215
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-1157
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Country | US
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Telephone | 586-263-2308
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Fax |
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Provider Business Mailing Address
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Address Line | 1 FORD PL STE 3A
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City | DETROIT
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State | MI
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Zip | 48202-3450
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Country | US
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Telephone | 313-876-4806
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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 |
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601011142
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License Number State | MI
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