MEDICARE: KATE LYNETTE CVETKOVSKI

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	363AM0700X	Medical Physician Assistant	5601010221	MI
2	363A00000X	Physician Assistant	5601010221	MI

General Provider Information

NPI Number	:	1336755156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATE LYNETTE CVETKOVSKI

Provider Business Mailing Address
First Line	:	55772 WOODRIDGE DR
Second Line	:
City	:	SHELBY TWP
State	:	MI
Zip	:	48316-1037
Country	:	US
Telephone Number	:	248-495-2154
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 W MAPLE RD
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3148
Country	:	US
Telephone Number	:	248-885-8211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	09/17/2020

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