Provider Demographics
NPI:1114021482
Name:PELLETIER, ELIZABETH MARGERY (PAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARGERY
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6321 S CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9170
Mailing Address - Country:US
Mailing Address - Phone:517-896-2946
Mailing Address - Fax:
Practice Address - Street 1:1140 E MICHIGAN AVE STE 300
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-5655
Practice Address - Fax:517-364-5654
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006896363A00000X
TXPA04209363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28445Medicare UPIN
TX8G3476Medicare ID - Type Unspecified