Provider Demographics
NPI:1508102922
Name:AUBREY, MARY THERESE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:AUBREY
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 1:7345 CHULA VISTA LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3917
Mailing Address - Country:US
Mailing Address - Phone:313-570-7094
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD STE 600
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1267
Practice Address - Country:US
Practice Address - Phone:248-967-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant