Provider Demographics
NPI:1790278778
Name:KEJBOU, AMANDA PUTRUS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:PUTRUS
Last Name:KEJBOU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PUTRUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:37000 GRAND RIVER AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2868
Mailing Address - Country:US
Mailing Address - Phone:248-536-2127
Mailing Address - Fax:
Practice Address - Street 1:27204 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1348
Practice Address - Country:US
Practice Address - Phone:248-513-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601008688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant