Provider Demographics
NPI:1417318478
Name:CHOULAGH, REANNE PUTRUS (PA-C)
Entity Type:Individual
Prefix:
First Name:REANNE
Middle Name:PUTRUS
Last Name:CHOULAGH
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 1:48528 ISOLA DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48528 ISOLA DR
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4138
Practice Address - Country:US
Practice Address - Phone:248-977-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant