Provider Demographics
NPI:1972949840
Name:PATZKE, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:PATZKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2729
Mailing Address - Country:US
Mailing Address - Phone:810-629-0336
Mailing Address - Fax:
Practice Address - Street 1:32669 WARREN RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-1677
Practice Address - Country:US
Practice Address - Phone:734-762-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5822464OtherBLUE CROSS