Provider Demographics
NPI:1902837677
Name:DUA, PEARL (PA)
Entity Type:Individual
Prefix:MS
First Name:PEARL
Middle Name:
Last Name:DUA
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 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-582-7070
Mailing Address - Fax:586-582-7066
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-582-7070
Practice Address - Fax:586-582-7066
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004694363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004694OtherLICENSE NUMBER
MI5601004694OtherLICENSE NUMBER
MIQ61958Medicare UPIN