Basic Information
| Provider Information | |||||||||
| NPI: | 1023068863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KACZMAREK | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | STEPHANIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36367 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480352958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867916868 | ||||||||
| FaxNumber: | 5867915071 | ||||||||
| Practice Location | |||||||||
| Address1: | 36367 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480352958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867916868 | ||||||||
| FaxNumber: | 5867915071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601001308 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.