Provider Demographics
NPI:1205065547
Name:RAMBUS, MARY ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:RAMBUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4646 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1916
Mailing Address - Country:US
Mailing Address - Phone:313-576-1000
Mailing Address - Fax:313-576-1112
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:313-576-1112
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8407481744R1102X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1744R1102XOther Service ProvidersSpecialistResearch Study
Provider Identifiers
StateIdentifier IDID TypeIssuer
840748OtherPHYSICIAN ASSISTANT