Provider Demographics
NPI:1407037716
Name:LICA, DORU (PA)
Entity Type:Individual
Prefix:
First Name:DORU
Middle Name:
Last Name:LICA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 PRINCESS DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1143
Mailing Address - Country:US
Mailing Address - Phone:734-718-2878
Mailing Address - Fax:
Practice Address - Street 1:4967 CROOKS RD
Practice Address - Street 2:SUITE 130
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5801
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant