Provider Demographics
NPI:1548282098
Name:PECK, DEBORAH LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LYNN
Last Name:PECK
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 1:4620 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-7200
Mailing Address - Fax:810-606-7115
Practice Address - Street 1:4620 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8067
Practice Address - Country:US
Practice Address - Phone:810-606-7200
Practice Address - Fax:810-606-7115
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004573363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P24400001Medicare ID - Type Unspecified