Provider Demographics
NPI:1649987488
Name:EVASIC, KAILEY (PA)
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:EVASIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 WESTBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1667
Mailing Address - Country:US
Mailing Address - Phone:248-504-1486
Mailing Address - Fax:
Practice Address - Street 1:55840 GRAND RIVER AVE STE 300
Practice Address - Street 2:
Practice Address - City:NEW HUDSON
Practice Address - State:MI
Practice Address - Zip Code:48165-9717
Practice Address - Country:US
Practice Address - Phone:248-264-6169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical