Provider Demographics
NPI:1619167657
Name:SOMMARIVA, EVELYN RUTH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:RUTH
Last Name:SOMMARIVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:EVELYN
Other - Middle Name:RUTH
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:43151 DALCOMA DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:586-286-8723
Practice Address - Street 1:285 N. LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4849
Practice Address - Country:US
Practice Address - Phone:734-495-1506
Practice Address - Fax:734-495-1780
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F31794OtherBCBS OF MI
MI0N30590Medicare PIN