Provider Demographics
NPI:1588378855
Name:GEEVARGHESE, MAREENA SUSAN (PA-C)
Entity type:Individual
Prefix:
First Name:MAREENA
Middle Name:SUSAN
Last Name:GEEVARGHESE
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 1:5875 ASHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3993
Mailing Address - Country:US
Mailing Address - Phone:858-692-7078
Mailing Address - Fax:
Practice Address - Street 1:5875 ASHWOOD DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3993
Practice Address - Country:US
Practice Address - Phone:858-692-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant