Provider Demographics
NPI:1467165266
Name:DECLERCQ, ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:DECLERCQ
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 1:3000 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2595
Mailing Address - Country:US
Mailing Address - Phone:419-530-5408
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE # MS 1027
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-530-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant