Basic Information
| Provider Information | |||||||||
| NPI: | 1326304239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | CREDENTIALING DEPT | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 8662506385 | ||||||||
| Practice Location | |||||||||
| Address1: | 33155 ANNAPOLIS ST | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481842405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344674042 | ||||||||
| FaxNumber: | 7344675500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2012 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601006350 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA11042 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 12403275 | 01 | MI | CAQH | OTHER |