Provider Demographics
NPI:1346739224
Name:TSACOUMANGOS, BRIAN JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAMES
Last Name:TSACOUMANGOS
Suffix:
Gender:M
Credentials:PA-C
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Other - Middle Name:
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Mailing Address - Street 1:5689 FRANCESCA LN
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5752
Mailing Address - Country:US
Mailing Address - Phone:586-295-0734
Mailing Address - Fax:
Practice Address - Street 1:2900 HANNAH BLVD STE 114
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5380
Practice Address - Country:US
Practice Address - Phone:517-364-8080
Practice Address - Fax:517-364-8088
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-06
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5315090741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346739224Medicaid