Provider Demographics
NPI:1174688600
Name:D'ALLEMAND, GEOFFREY THANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:THANE
Last Name:D'ALLEMAND
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 1:126 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1706
Mailing Address - Country:US
Mailing Address - Phone:248-399-0973
Mailing Address - Fax:
Practice Address - Street 1:19401 HUBBARD DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2641
Practice Address - Country:US
Practice Address - Phone:313-982-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical