Provider Demographics
NPI:1265550487
Name:LILLA, CLAUDINE (PA-C)
Entity type:Individual
Prefix:
First Name:CLAUDINE
Middle Name:
Last Name:LILLA
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 1:6071 W OUTER DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2624
Mailing Address - Country:US
Mailing Address - Phone:313-966-1696
Mailing Address - Fax:318-966-4773
Practice Address - Street 1:6071 W OUTER DR DEPT OF
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-1696
Practice Address - Fax:318-966-4773
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003179363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical