=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528243003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA MARIE PARCHOMENKO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2008
-----------------------------------------------------
Last Update Date | 02/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2799 W GRAND BLVD K-8
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-916-2600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48516 LORENZO DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-363-4146
-----------------------------------------------------
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 | 5601005121
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------