Provider Demographics
NPI:1477879492
Name:KOUASSI, KONAN EUGENE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KONAN
Middle Name:EUGENE
Last Name:KOUASSI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 CHRISTOPHER LN APT 318
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1352
Mailing Address - Country:US
Mailing Address - Phone:313-283-8258
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:STE 485
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-552-9050
Practice Address - Fax:248-552-1290
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477879492Medicaid