MEDICARE: NICOLE SAPIRO VINCKIER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601007743	MI

General Provider Information

NPI Number	:	1174976740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLE SAPIRO VINCKIER

Provider Business Mailing Address
First Line	:	1307 WEBSTER ST
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-7090
Country	:	US
Telephone Number	:	818-726-3262
Fax Number	:

Provider Business Practice Location Address
First Line	:	35046 WOODWARD AVE
Second Line	:	STE 100
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-0964
Country	:	US
Telephone Number	:	248-647-9860
Fax Number	:	248-647-9864

Authorized Official
Title or Position	:	CO-OWNER AUTHORIZED OFFICIAL
Name	:	MR. JOHN R SANBORN
Credential	:	M.D.
Telephone Number	:	248-647-9860

Provider Enumeration Date	:	07/19/2016
Last Update Date	:	07/19/2016

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