Provider Demographics
NPI:1942869300
Name:KONSITZKE, LAURA DOROTHY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:DOROTHY
Last Name:KONSITZKE
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:38136 KLARR DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9036
Mailing Address - Country:US
Mailing Address - Phone:248-880-8638
Mailing Address - Fax:
Practice Address - Street 1:22201 MOROSS RD STE 380
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2176
Practice Address - Country:US
Practice Address - Phone:877-784-3667
Practice Address - Fax:313-343-4567
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601009074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant