Provider Demographics
NPI:1831166768
Name:STACHOWIAK, TODD P (PA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:P
Last Name:STACHOWIAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 GRATIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2121
Mailing Address - Country:US
Mailing Address - Phone:810-364-4000
Mailing Address - Fax:810-364-5995
Practice Address - Street 1:3350 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2121
Practice Address - Country:US
Practice Address - Phone:810-364-4000
Practice Address - Fax:810-364-5995
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831166768Medicaid
MI1831166768Medicaid