Provider Demographics
NPI:1174714372
Name:DELY, JILL F (PA-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:F
Last Name:DELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-574-0890
Mailing Address - Fax:586-574-9321
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-574-0890
Practice Address - Fax:586-574-9321
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005004363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005004OtherSTATE LICENSE