Provider Demographics
NPI:1891815411
Name:DEGRAFF, NICOLE SUZANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZANNE
Last Name:DEGRAFF
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 1:295 JAMIE DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-8648
Mailing Address - Country:US
Mailing Address - Phone:517-227-4067
Mailing Address - Fax:
Practice Address - Street 1:624 MENDON RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:MI
Practice Address - Zip Code:49094-8741
Practice Address - Country:US
Practice Address - Phone:517-741-7989
Practice Address - Fax:517-741-7188
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ23698Medicare UPIN