Basic Information
| Provider Information | |||||||||
| NPI: | 1598787079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEBSTER | ||||||||
| FirstName: | DEANGELO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17197 N LAUREL PARK DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481527910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343388300 | ||||||||
| FaxNumber: | 7342375405 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 EUREKA RD STE B | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342259300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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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 | 363A00000X | 5601002997 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 5601002997 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.