Basic Information
Provider Information | |||||||||
NPI: | 1912348269 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROULS | ||||||||
FirstName: | VALERIE | ||||||||
MiddleName: | SAMMUT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SAMMUT | ||||||||
OtherFirstName: | VALERIE | ||||||||
OtherMiddleName: | SUZANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | ONE HURLEY PLAZA | ||||||||
Address2: | SON, 5TH FLOOR | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485035993 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102629353 | ||||||||
FaxNumber: | 8107600440 | ||||||||
Practice Location | |||||||||
Address1: | ONE HURLEY PLAZA | ||||||||
Address2: | 7W | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485035993 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102629355 | ||||||||
FaxNumber: | 8102626341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2013 | ||||||||
LastUpdateDate: | 10/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5601006677 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.