Provider Demographics
NPI:1962455055
Name:WOODARD, LAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAINE
Middle Name:
Last Name:WOODARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:DELMONICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:57435 SPAULDING CT
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9824
Mailing Address - Country:US
Mailing Address - Phone:248-359-1008
Mailing Address - Fax:248-353-6193
Practice Address - Street 1:24500 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2414
Practice Address - Country:US
Practice Address - Phone:248-359-1008
Practice Address - Fax:248-353-6193
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH26107195Medicare PIN