Basic Information
| Provider Information | |||||||||
| NPI: | 1023304417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2864 ASHMUN ST | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497833740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325200 | ||||||||
| FaxNumber: | 9066325276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2864 ASHMUN ST | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497833740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325200 | ||||||||
| FaxNumber: | 9066325276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601006060 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.