Provider Demographics
NPI:1831134394
Name:AULTMAN, DEBORAH A (PAC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:AULTMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W MAIN ST
Mailing Address - Street 2:PO BOX 818
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9239
Mailing Address - Country:US
Mailing Address - Phone:989-831-7723
Mailing Address - Fax:989-831-8303
Practice Address - Street 1:620 W MAIN ST
Practice Address - Street 2:PO 818
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9239
Practice Address - Country:US
Practice Address - Phone:989-427-3331
Practice Address - Fax:989-427-3037
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDA003901OtherBLUE CROSS
MIN83930008Medicare PIN
MIDA003901OtherBLUE CROSS