Basic Information
| Provider Information | |||||||||
| NPI: | 1558671263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRATZ | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 23664 COPPERWOOD DR E | ||||||||
| Address2: | |||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481788274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242727542 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4400 S SAGINAW ST | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103910662 | ||||||||
| FaxNumber: | 8102398330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601005900 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.