Provider Demographics
NPI:1962770917
Name:MERAM, MANDA MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MANDA
Middle Name:MARIE
Last Name:MERAM
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 1:700 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5580
Mailing Address - Country:US
Mailing Address - Phone:903-315-2000
Mailing Address - Fax:
Practice Address - Street 1:7125 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3615
Practice Address - Country:US
Practice Address - Phone:248-865-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006203363A00000X
TXPA08484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant