Provider Demographics
NPI:1386696912
Name:DORAIS, NEITA I (ANP B-C)
Entity type:Individual
Prefix:
First Name:NEITA
Middle Name:I
Last Name:DORAIS
Suffix:
Gender:F
Credentials:ANP B-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 105TH AVE
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49346-9764
Mailing Address - Country:US
Mailing Address - Phone:231-972-2710
Mailing Address - Fax:231-972-2712
Practice Address - Street 1:8540 105TH AVE
Practice Address - Street 2:
Practice Address - City:CANADIAN LAKES
Practice Address - State:MI
Practice Address - Zip Code:49346-9764
Practice Address - Country:US
Practice Address - Phone:231-972-2710
Practice Address - Fax:231-972-2712
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704144505363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4893736Medicaid
MI4843645Medicaid
MIE46007015Medicare UPIN
MIE46007015Medicare PIN
MIP32930003Medicare ID - Type Unspecified
MIN26180018Medicare ID - Type Unspecified