Provider Demographics
NPI:1639105372
Name:PROKOSCH, JAN HAZEL (FNPC)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:HAZEL
Last Name:PROKOSCH
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SANDPOINT RD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1406
Mailing Address - Country:US
Mailing Address - Phone:906-387-4110
Mailing Address - Fax:906-387-3514
Practice Address - Street 1:1500 SANDPOINT RD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1406
Practice Address - Country:US
Practice Address - Phone:906-387-4110
Practice Address - Fax:906-387-3514
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008770770OtherBLUE CROSS BLUE SHIELD
MI5008770770OtherBLUE CROSS BLUE SHIELD
P92372Medicare UPIN
P17990004Medicare PIN