MEDICARE: KRISTIN NICOLE IANNOTTI PA-C

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	5601009620	MI

General Provider Information

NPI Number	:	1497392005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN NICOLE IANNOTTI PA-C

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD STE 3D
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:	947-522-1848
Fax Number	:	947-522-0307

Provider Business Practice Location Address
First Line	:	555 BARCLAY CIR STE 150
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-4587
Country	:	US
Telephone Number	:	248-299-5777
Fax Number	:	248-299-6917

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

Provider Enumeration Date	:	12/02/2019
Last Update Date	:	07/08/2022

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