Provider Demographics
NPI:1013461581
Name:DEGROAT, AUTUMN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ELIZABETH
Last Name:DEGROAT
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:PO BOX 320008
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0001
Mailing Address - Country:US
Mailing Address - Phone:989-495-2050
Mailing Address - Fax:989-495-2095
Practice Address - Street 1:111 E WACKERLY ST STE D
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-7043
Practice Address - Country:US
Practice Address - Phone:989-495-2050
Practice Address - Fax:989-495-2095
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58848363A00000X
MI5601007826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA58848OtherSTATE MEDICAL LICENSE