Provider Demographics
NPI:1508243031
Name:DAWISHA, CANDACE CHRISTINE (PA)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:CHRISTINE
Last Name:DAWISHA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:CANDACE
Other - Middle Name:CHRISTINE
Other - Last Name:BABBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6325 GOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3094
Mailing Address - Country:US
Mailing Address - Phone:248-756-5775
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant