Provider Demographics
NPI:1649731076
Name:MIRCH, JANELLE MAUREEN (PA-C)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:MAUREEN
Last Name:MIRCH
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 1:587 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-2647
Mailing Address - Country:US
Mailing Address - Phone:248-431-6742
Mailing Address - Fax:
Practice Address - Street 1:44199 DEQUINDRE RD STE 315
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant