Provider Demographics
NPI:1114708609
Name:KORICAN, SAMUEL T (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:T
Last Name:KORICAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W MICHIGAN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1900
Mailing Address - Country:US
Mailing Address - Phone:517-205-7618
Mailing Address - Fax:
Practice Address - Street 1:744 W MICHIGAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1900
Practice Address - Country:US
Practice Address - Phone:517-205-7618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601012137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant