Provider Demographics
NPI:1033107271
Name:PROVOAST, DEBRA K (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:K
Last Name:PROVOAST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-0279
Mailing Address - Country:US
Mailing Address - Phone:989-728-6000
Mailing Address - Fax:989-728-6003
Practice Address - Street 1:3190 NORTHRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9276
Practice Address - Country:US
Practice Address - Phone:989-728-6000
Practice Address - Fax:989-728-6003
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173663363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDP173663OtherLICENSE
MI105235126Medicaid
MI500C510200OtherBCBS
S92769Medicare UPIN
MI0P24490Medicare PIN