Provider Demographics
NPI:1891472221
Name:FUSCO, DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FUSCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:5701 BOW POINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3199
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2622
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant