Provider Demographics
NPI:1679693436
Name:JOLLY, WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:JOLLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-8381
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:KARMANOS CANCER CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8381
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2016-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant