Provider Demographics
NPI:1396851473
Name:FAUST, ALLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:FAUST
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 1:3035 S 26TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-9610
Mailing Address - Country:US
Mailing Address - Phone:269-383-4285
Mailing Address - Fax:
Practice Address - Street 1:7901 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0714
Practice Address - Country:US
Practice Address - Phone:269-324-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI757-4431Medicaid
MISO-1528Medicare UPIN
MIOM-87110Medicare ID - Type Unspecified