Provider Demographics
NPI:1710024161
Name:THIBODEAU-ASHFORD, ANN C (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:C
Last Name:THIBODEAU-ASHFORD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:C
Other - Last Name:THIBODEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:177 N BARLOW RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-9607
Mailing Address - Country:US
Mailing Address - Phone:989-736-8157
Mailing Address - Fax:989-358-3762
Practice Address - Street 1:177 N BARLOW RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9607
Practice Address - Country:US
Practice Address - Phone:989-736-8157
Practice Address - Fax:989-358-3762
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S55510Medicare UPIN
MIZ16001057Medicare PIN