Provider Demographics
NPI:1053327957
Name:MICELI, MARY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MICELI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:RAMSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:422 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1224
Mailing Address - Country:US
Mailing Address - Phone:248-348-1131
Mailing Address - Fax:248-348-1170
Practice Address - Street 1:422 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1224
Practice Address - Country:US
Practice Address - Phone:483-481-1312
Practice Address - Fax:248-348-1170
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00083625OtherRAILROAD MEDICARE
MIP00083625OtherRAILROAD MEDICARE
MIMR0984321OtherDEA
P78075Medicare UPIN