Provider Demographics
NPI:1396138251
Name:KALIS, DEBRA LINDA-JACKMAN (PA-C)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:LINDA-JACKMAN
Last Name:KALIS
Suffix:
Gender:F
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 1:16001 W 9 MILE RD # 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-2600
Mailing Address - Fax:248-849-2610
Practice Address - Street 1:16001 W 9 MILE RD # 3
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-2600
Practice Address - Fax:248-849-2610
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant