MEDICARE: KAILEY EVASIC PA

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	5601011330	MI

General Provider Information

NPI Number	:	1649987488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAILEY EVASIC PA

Provider Business Mailing Address
First Line	:	859 WESTBROOKE DR
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-1667
Country	:	US
Telephone Number	:	248-504-1486
Fax Number	:

Provider Business Practice Location Address
First Line	:	55840 GRAND RIVER AVE STE 300
Second Line	:
City	:	NEW HUDSON
State	:	MI
Zip	:	48165-9717
Country	:	US
Telephone Number	:	248-264-6169
Fax Number	:

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

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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Directions to “ KAILEY EVASIC PA” Practice Location

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