Provider Demographics
NPI:1487395455
Name:BHARATHAN, MAYURI (PA-C)
Entity type:Individual
Prefix:
First Name:MAYURI
Middle Name:
Last Name:BHARATHAN
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 1:2856 CHARTER DR APT 217
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1386
Mailing Address - Country:US
Mailing Address - Phone:734-205-8526
Mailing Address - Fax:
Practice Address - Street 1:4301 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6411
Practice Address - Country:US
Practice Address - Phone:586-722-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010863363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical