Provider Demographics
NPI:1245208222
Name:SUDBURY, KARYN ANNE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:KARYN
Middle Name:ANNE
Last Name:SUDBURY
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3577 W 13 MILE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-0669
Practice Address - Fax:248-551-0058
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ31267Medicare UPIN
MI0N33470093Medicare ID - Type Unspecified