Provider Demographics
NPI:1023068863
Name:KACZMAREK, DIANE STEPHANIE (PA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:STEPHANIE
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36367 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2958
Mailing Address - Country:US
Mailing Address - Phone:586-791-6868
Mailing Address - Fax:586-791-5071
Practice Address - Street 1:36367 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2958
Practice Address - Country:US
Practice Address - Phone:586-791-6868
Practice Address - Fax:586-791-5071
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR68651Medicare UPIN
MIN40170069Medicare ID - Type UnspecifiedMEDICARE