Provider Demographics
NPI:1770788226
Name:KILDANI, TABITHA (PA)
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:KILDANI
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 1:1905 VENICE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4140
Mailing Address - Country:US
Mailing Address - Phone:313-522-0306
Mailing Address - Fax:
Practice Address - Street 1:861 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2308
Practice Address - Country:US
Practice Address - Phone:313-274-1800
Practice Address - Fax:313-277-4011
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN97990003Medicare PIN