Provider Demographics
NPI:1093700981
Name:SEBEST, CHARLENE L (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:L
Last Name:SEBEST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:L
Other - Last Name:MCNIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:19229 MACK AVE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2858
Mailing Address - Country:US
Mailing Address - Phone:313-884-5522
Mailing Address - Fax:313-884-6054
Practice Address - Street 1:19229 MACK AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236-2858
Practice Address - Country:US
Practice Address - Phone:313-884-5522
Practice Address - Fax:313-884-6054
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002989363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093700981OtherNPI #
MI1093700981OtherNPI #
MIM71670319Medicare PIN
MIP28070061Medicare PIN