Provider Demographics
NPI:1366413411
Name:PRUSINOWSKI, JAN (PA-C)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:PRUSINOWSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 HIGHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1548
Mailing Address - Country:US
Mailing Address - Phone:313-563-6340
Mailing Address - Fax:
Practice Address - Street 1:1500 EUREKA RD
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-6103
Practice Address - Country:US
Practice Address - Phone:734-282-2500
Practice Address - Fax:734-282-6397
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001290363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R68545Medicare UPIN
0N41950Medicare ID - Type Unspecified