Provider Demographics
NPI:1669634499
Name:MENON, REMA PALISSERY (PA)
Entity Type:Individual
Prefix:
First Name:REMA
Middle Name:PALISSERY
Last Name:MENON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REMA
Other - Middle Name:PALISSERY
Other - Last Name:MENON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:41267 SCARBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2892
Mailing Address - Country:US
Mailing Address - Phone:248-987-6252
Mailing Address - Fax:
Practice Address - Street 1:41267 SCARBOROUGH LN
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2892
Practice Address - Country:US
Practice Address - Phone:248-987-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005227OtherPHYSICIAN'S ASSISTANT LINCENSE