Provider Demographics
NPI:1083868483
Name:SIDOR, DEBORAH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:SIDOR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9655 SHEARSON CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3640
Mailing Address - Country:US
Mailing Address - Phone:734-414-9461
Mailing Address - Fax:
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-465-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704125686163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse