Provider Demographics
NPI:1164173001
Name:DUCUSIN, JEREMIAH BACALSO (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:BACALSO
Last Name:DUCUSIN
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:50083 MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-6340
Mailing Address - Country:US
Mailing Address - Phone:586-412-0838
Mailing Address - Fax:586-412-0838
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical