Provider Demographics
NPI:1740527290
Name:SYDLOSKI, EMILY ANNE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:SYDLOSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:NYLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 28TH ST SW STE B
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1282
Mailing Address - Country:US
Mailing Address - Phone:616-949-9030
Mailing Address - Fax:616-949-9076
Practice Address - Street 1:1009 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1710
Practice Address - Country:US
Practice Address - Phone:269-948-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant