Provider Demographics
NPI:1689611402
Name:GRIFKA, DEANNA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:
Last Name:GRIFKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:
Other - Last Name:DAKROUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE # 111
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-573-5300
Mailing Address - Fax:586-573-5304
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE # 111
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-573-5300
Practice Address - Fax:586-573-5304
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103122363A00000X
MI5601004096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29Z314900Medicaid
MIM57830007OtherMEDICARE NUMBER
FL292314900Medicaid
FL29Z314900Medicaid