Provider Demographics
NPI:1174560106
Name:HILL, DEODGE MONIQUE (PAC)
Entity type:Individual
Prefix:
First Name:DEODGE
Middle Name:MONIQUE
Last Name:HILL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46036 MICHIGAN AVE
Mailing Address - Street 2:# 318
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2304
Mailing Address - Country:US
Mailing Address - Phone:734-345-9023
Mailing Address - Fax:734-328-5944
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:810-765-8169
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063098OtherNCCPA CERTIFICATE NUMBER