Provider Demographics
NPI:1881449759
Name:MARINER, RACHEL ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:MARINER
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 1:14682 FORDLINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2549
Mailing Address - Country:US
Mailing Address - Phone:734-819-3699
Mailing Address - Fax:
Practice Address - Street 1:311 MACK AVE # 61100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2466
Practice Address - Country:US
Practice Address - Phone:248-246-6468
Practice Address - Fax:248-294-1427
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2025-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601012715363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant