Provider Demographics
NPI:1639688393
Name:CLAYTON, COLETTE MARIE ICASIANO (MS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:COLETTE
Middle Name:MARIE ICASIANO
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:MS, PA-C
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Mailing Address - Street 1:47045 ROSEMARY RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2582
Mailing Address - Country:US
Mailing Address - Phone:586-744-5185
Mailing Address - Fax:
Practice Address - Street 1:39621 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4302
Practice Address - Country:US
Practice Address - Phone:586-226-5555
Practice Address - Fax:586-226-4441
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2022-09-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant