Provider Demographics
NPI:1942296116
Name:MOTT, CAROL P (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:P
Last Name:MOTT
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 1:24901 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1384
Mailing Address - Country:US
Mailing Address - Phone:586-772-9055
Mailing Address - Fax:586-772-0543
Practice Address - Street 1:24901 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1384
Practice Address - Country:US
Practice Address - Phone:586-772-9055
Practice Address - Fax:586-772-0543
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION18730Medicare ID - Type Unspecified