Provider Demographics
NPI:1396779005
Name:PERRAUT, MARIANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:
Last Name:PERRAUT
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 1:133 S MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2308
Mailing Address - Country:US
Mailing Address - Phone:586-465-1326
Mailing Address - Fax:586-465-0329
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2308
Practice Address - Country:US
Practice Address - Phone:586-465-1326
Practice Address - Fax:586-465-0329
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003881363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP87980Medicare UPIN
MION70890Medicare ID - Type Unspecified