Provider Demographics
NPI:1134109531
Name:VAN OAST, JOANN (PA)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:VAN OAST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17800 NEWBURGH RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2700
Mailing Address - Country:US
Mailing Address - Phone:734-464-9540
Mailing Address - Fax:734-464-0438
Practice Address - Street 1:17800 NEWBURGH RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2700
Practice Address - Country:US
Practice Address - Phone:734-464-9540
Practice Address - Fax:734-464-0438
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P51863Medicare UPIN