Provider Demographics
NPI:1720389281
Name:PEYSAKHOV, JAMIE (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PEYSAKHOV
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 26 MILE RD 300
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5139
Mailing Address - Country:US
Mailing Address - Phone:586-786-5900
Mailing Address - Fax:586-992-9331
Practice Address - Street 1:8180 26 MILE RD 300
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-5139
Practice Address - Country:US
Practice Address - Phone:586-786-5900
Practice Address - Fax:586-992-9331
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant