Provider Demographics
NPI:1417076316
Name:FAMIGLIETTI, GARY (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FAMIGLIETTI
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 1:4100 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2013
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-8381
Practice Address - Street 1:1560 E MAPLE RD
Practice Address - Street 2:SUITE 400 - CREDENTIALING DEPARTMENT
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8381
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001499363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical