Provider Demographics
NPI:1740299981
Name:PROVENCHER, DENISE PATRICIA (PA-C)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:PATRICIA
Last Name:PROVENCHER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25500 MEADOWBROOK RD STE 150
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1880
Mailing Address - Country:US
Mailing Address - Phone:248-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:25500 MEADOWBROOK RD STE 150
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1880
Practice Address - Country:US
Practice Address - Phone:248-784-3667
Practice Address - Fax:248-869-3982
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant