Provider Demographics
NPI:1518260884
Name:MAIORANA, COLBY L (PAC)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:L
Last Name:MAIORANA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21031 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2339
Mailing Address - Country:US
Mailing Address - Phone:313-277-6700
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 3R
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI5601006690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
12564682OtherCAQH