Provider Demographics
NPI:1629024666
Name:KOMINIAREK, NANCY (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:KOMINIAREK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25311 LITTLE MACK
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-498-2400
Mailing Address - Fax:586-498-2800
Practice Address - Street 1:25311 LITTLE MACK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3301
Practice Address - Country:US
Practice Address - Phone:586-498-2400
Practice Address - Fax:586-498-2800
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant