Provider Demographics
NPI:1912474875
Name:COURETAS, MARY BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:COURETAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:REINKEMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2448 ARMSTRONG DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1909
Mailing Address - Country:US
Mailing Address - Phone:573-690-1877
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant