Provider Demographics
NPI:1912056896
Name:WAKADE, PRANJALI S (PA)
Entity Type:Individual
Prefix:
First Name:PRANJALI
Middle Name:S
Last Name:WAKADE
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:PO BOX 321068
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0019
Mailing Address - Country:US
Mailing Address - Phone:810-720-0639
Mailing Address - Fax:810-230-1978
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-720-0639
Practice Address - Fax:810-230-1978
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1036162OtherNCCPA
MI5601002868OtherLICENSE
MI5601002868OtherLICENSE