Provider Demographics
NPI:1871898320
Name:PERDOMO, VANESSA DANETTE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:DANETTE
Last Name:PERDOMO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:DANETTE
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5000
Practice Address - Fax:248-652-5014
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12552858OtherCAQH