Provider Demographics
NPI:1295750677
Name:MITCHELL, INGRID DOMINIC (PA)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:DOMINIC
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:390 ENTERPRISE CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0320
Mailing Address - Country:US
Mailing Address - Phone:248-336-4000
Mailing Address - Fax:248-336-9137
Practice Address - Street 1:18254 LIVERNOIS AVE STE 1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-4214
Practice Address - Country:US
Practice Address - Phone:313-861-4400
Practice Address - Fax:248-336-9137
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-06-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003504363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI31377Medicare ID - Type Unspecified