Provider Demographics
NPI:1053567669
Name:DENIO, JEFFREY T (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:DENIO
Suffix:
Gender:M
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 1:6815 DIXIE HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2092
Mailing Address - Country:US
Mailing Address - Phone:248-384-8350
Mailing Address - Fax:248-384-8351
Practice Address - Street 1:155 EAGLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-2612
Practice Address - Country:US
Practice Address - Phone:489-824-9452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005283363AM0700X
MI1053567669363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200F311140OtherBCBSM
MI200F311140OtherBCBSM