Provider Demographics
NPI:1689328692
Name:ANDERSON, SUMMER MOFFAT (PA-C)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:MOFFAT
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43141 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5005
Mailing Address - Country:US
Mailing Address - Phone:248-333-0333
Mailing Address - Fax:
Practice Address - Street 1:122 E BROWN ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6201
Practice Address - Country:US
Practice Address - Phone:248-731-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical