Provider Demographics
NPI:1003569195
Name:BOCK, NINA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:MARIE
Last Name:BOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:MARIE
Other - Last Name:PALUSHAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:248-990-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-30
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant