Provider Demographics
NPI:1083970297
Name:PUTT, ELIZABETH ANN
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:PUTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:ESTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33166 MAPLENUT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4437
Mailing Address - Country:US
Mailing Address - Phone:734-231-9548
Mailing Address - Fax:
Practice Address - Street 1:33166 MAPLENUT ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-4437
Practice Address - Country:US
Practice Address - Phone:734-231-9548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant