Provider Demographics
NPI:1841766599
Name:ABRAHAM, NITHA MARY (PA)
Entity Type:Individual
Prefix:MISS
First Name:NITHA
Middle Name:MARY
Last Name:ABRAHAM
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 1:15120 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3768
Mailing Address - Country:US
Mailing Address - Phone:313-843-8300
Mailing Address - Fax:
Practice Address - Street 1:15120 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3768
Practice Address - Country:US
Practice Address - Phone:313-843-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty