Provider Demographics
NPI:1265029144
Name:ABBO, MIRANDA DAVINA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DAVINA
Last Name:ABBO
Suffix:
Gender:F
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 1:1770 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1904
Mailing Address - Country:US
Mailing Address - Phone:313-466-4000
Mailing Address - Fax:
Practice Address - Street 1:1770 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1904
Practice Address - Country:US
Practice Address - Phone:313-466-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care