Provider Demographics
NPI:1851868228
Name:CRNOMARKOVIC, GORAN
Entity Type:Individual
Prefix:
First Name:GORAN
Middle Name:
Last Name:CRNOMARKOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30795 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5720
Mailing Address - Country:US
Mailing Address - Phone:586-277-0502
Mailing Address - Fax:
Practice Address - Street 1:30795 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5720
Practice Address - Country:US
Practice Address - Phone:586-277-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant