Provider Demographics
NPI:1891780789
Name:PATERYN, JENNY S (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:S
Last Name:PATERYN
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 1:29355 NORTHWESTERN HWY
Mailing Address - Street 2:# 302
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1053
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP F
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5332
Practice Address - Country:US
Practice Address - Phone:734-936-5738
Practice Address - Fax:734-936-6927
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP28070010Medicare ID - Type Unspecified
S75774Medicare UPIN