Provider Demographics
NPI:1366739187
Name:GREENWALD, YAFFA SHAINDEL (PAC)
Entity type:Individual
Prefix:
First Name:YAFFA
Middle Name:SHAINDEL
Last Name:GREENWALD
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 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:888-861-8740
Mailing Address - Fax:866-250-6385
Practice Address - Street 1:33155 ANNAPOLIS ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-467-4042
Practice Address - Fax:734-467-5500
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12276823OtherCAQH