Provider Demographics
NPI:1831199264
Name:AMIN, GAYATRI R (PA-C)
Entity type:Individual
Prefix:
First Name:GAYATRI
Middle Name:R
Last Name:AMIN
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 1:1979 SHEFFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:817-707-9225
Mailing Address - Fax:
Practice Address - Street 1:8750 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2322
Practice Address - Country:US
Practice Address - Phone:248-590-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03090363A00000X
NJ25MP00237500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ11980Medicare UPIN
NJG73299Medicare UPIN