Provider Demographics
NPI:1861926636
Name:DEKA, PALLAV (PHD, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:PALLAV
Middle Name:
Last Name:DEKA
Suffix:
Gender:M
Credentials:PHD, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-694-2144
Mailing Address - Fax:517-694-7469
Practice Address - Street 1:5091 WILLOUGHBY RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1054
Practice Address - Country:US
Practice Address - Phone:517-694-2144
Practice Address - Fax:517-694-7469
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704350380363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology