Basic Information
| Provider Information | |||||||||
| NPI: | 1740299981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVENCHER | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6700 RIVES JUNCTION RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492017448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175693200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MP1005455 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.